LTAH Exhausted DRG?
Hi, all,
I'm hoping possibly the CDS(s) whose facility was featured in a recent CDI Journal (and others?) might respond to this question. At our facility we often transfer vent-dependent patients to LTAHs for vent weaning, often with a letter of agreement to accept the patient back. Recently, we transferred a patient to an LTAH and several weeks later our ICU case manager received a call from the case manager @ the LTAH, saying that the patient's DRG was exhausted & the patient was coming back to us. I'm not sure I understand the process for LTAHs, how they get paid if the DRG is "exhausted"? I understand that the LTAHs DRGs are the same as MS-DRGs, but definitely weighted differently (for average LOS of 25 days). Can someone do a "LTAHs 101" for me (briefly) so that I can help my ICU CM understand the whole process and the challenges of transferring between facilities? Or refer me to a good reference site? Do other CDSs experience this?
thanks very much,
Becky Mann, RN, CDS
Sutter Solano Medical Center
707-554-5392
I'm hoping possibly the CDS(s) whose facility was featured in a recent CDI Journal (and others?) might respond to this question. At our facility we often transfer vent-dependent patients to LTAHs for vent weaning, often with a letter of agreement to accept the patient back. Recently, we transferred a patient to an LTAH and several weeks later our ICU case manager received a call from the case manager @ the LTAH, saying that the patient's DRG was exhausted & the patient was coming back to us. I'm not sure I understand the process for LTAHs, how they get paid if the DRG is "exhausted"? I understand that the LTAHs DRGs are the same as MS-DRGs, but definitely weighted differently (for average LOS of 25 days). Can someone do a "LTAHs 101" for me (briefly) so that I can help my ICU CM understand the whole process and the challenges of transferring between facilities? Or refer me to a good reference site? Do other CDSs experience this?
thanks very much,
Becky Mann, RN, CDS
Sutter Solano Medical Center
707-554-5392
Comments
For a LTAC to get the full reimbursement, the patient's LOS must exceed 5/6th of the GLOS. The 5/6th for DRG 207 is 27.6 which means the LOS must be at least 28 days for full reimbursement. From that point until the charges reach the calculated reimbursement (rate x weight) PLUS the charge threshold for that DRG, there is no additional reimbursement.
For example: DRG 207 expected reimbursement = $80,968 PLUS Charge Threshold for DRG 207 = $501,873.39 for a total of $582,841.39. This means the LTAC will get $80,968 reimbursement until the charges reach $582,841.39. After that they will get approximately an additional 20% of the charges ABOVE $582,841.39. It is called a Cost Outlier when a patient reaches the Exp. Reimbursement + Charge Threshold point.
I imagine the term 'DRG exhausted' means the patient has reached the GLOS (or 5/6th GLOS).
There are also Short Stay Outliers (payment is reduced due to patient not reaching the 5/6th LOS),
CMS Medicare Learning Network (https://www.cms.gov/mlnproducts/) has great brochures on this. They explain it much better than I can.
If you have more questions, email me or give me a call.
Sharon Salinas, CCS
Health Information Management Department
Barlow Respiratory Hospital
2000 Stadium Way
Los Angeles, CA 90026
ssalinas@barlow2000.org
Phone: 213-250-4200 ext. 3336
Fax: 213-202-6490