Lots of things happening last week for me to talk about. First, still no sign of the 2026 Outpatient Prospective Payment System (OPPS) Final Rule. Many of us expected a Friday 5 p.m. release, but it did not happen. I wasn’t sure if I should have been sad or relieved. But the wait goes on.
I also heard back from the Centers for Medicare & Medicaid Services (CMS) about the soon-to-expire Medicare Outpatient Observation Notice (MOON), and they confirmed that we can keep using the expired form until the new version is released. Now, will they allow a grace period, once the new form is released? History says they will, but we won’t know until that day comes.
I have also received a lot of emails about my discussion about using the Against Medical Advice (AMA) designation for patients who not only insist on going home when the care team thinks it is unsafe, but also when a payor refuses to approve necessary and appropriate post-acute care, such as transfer to inpatient rehabilitation provider.
And one person brought up a very good point. As I discussed, the way to indicate the patient left AMA is to use discharge status code 07. The presence of that code excludes the admission from the Readmission Reduction Program and other quality programs. But if the patient goes home with home care services ordered and provided, then the claim should get discharge status code 06. If they go to a Skilled Nursing Facility (SNF), it is discharge status code 03. This is significant because of the Transfer Diagnosis-Related Group (DRG) payment adjustment for certain admissions for patients who receive post-acute care.
But unlike the fields on the claim that allow multiple condition codes, procedure codes, or diagnosis codes, the discharge status field only allows one code. So that person asked: What do we do?
Well, I first reached out to CMS, and amazingly, got a response that said claim preparation is not within their purview. I probably should have figured that. So, I reached out to the National Uniform Billing Committee (NUBC), which created the claim form. And their answer indicated that they never anticipated such an occurrence, and that “best judgment” should be used to select which code to use.
So, what would I recommend? Weil first, look at the working DRG, get the geometric mean length of stay (GMLOS), and see if the transfer DRG payment adjustment would apply. If the length of stay would not result in a payment adjustment, then go ahead and use the AMA code. But if the length of stay is more than one day less than the GMLOS, there is money at play, and you should probably talk to compliance to make a decision.
In other news, I just want to add a clarification. The title of last week’s Talk Ten Tuesdays segment suggested there was a new definition for sepsis. And that is not correct. Now, of course, there is continuing controversy over what sepsis really is, but there is no new definition. As you heard, what was new was that the Sequential Organ Failure Assessment (SOFA) criteria were refined, and now it is SOFA-2. But remember, the definition of sepsis absolutely does not require a SOFA-2 score of 2 or more. It requires organ dysfunction in the setting of an infection. But I will leave that to the ICD10monitor team to discuss.
Finally, I was recently at a conference, and one of the speakers was talking about length of stay as one of those ever-present Key Performance Indicators (KPIs). And while the speaker described the mathematical difference between average and geometric mean and the variable effects of outliers, the definition of length of stay was presented as “the number of days of the stay in the hospital.” And as I have discussed way too many times, CMS measures length of stay based on inpatient days, not total hospital days. Don’t fall into that trap.
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It’s two weeks into November, and still no Outpatient Prospective Payment System (OPPS) Final Rule from the Centers for Medicare & Medicaid Services (CMS). Now,
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