Hospitals participating with EmblemHealth are reminded to correctly identify and properly code whether patients are transferred or discharged, since this affects Medicaid hospital inpatient billing and payments. For additional information, providers can refer to the Medicaid Update article titled Medicaid Billing – Patient Status Codes.
Effective Aug. 21, 2021, the New York Codes, Rules and Regulations (NYCRR), Title 10, §86-1.15, defines discharges (in a general hospital acute care setting) as those inpatients whose admission to the facility occurred on or after Dec. 1, 2009, and the patient:
- Is released from the facility to a non-acute care setting; or
- Dies in the facility; or
- Is transferred to a facility or unit that is exempt from the case-based payment system, except when the patient is a newborn transferred to an exempt hospital for neonatal services; or
- Is a neonate being released from a hospital (providing neonatal specialty services) back to the community hospital of birth for weight gain.
A transfer patient is defined as a patient who:
- Is not discharged, as stated above.
- Is not transferred among two or more divisions of merged or consolidated facilities.
- Is not assigned to a Diagnosis Related Group (DRG) specifically identified as a DRG for transferred patients only.
- Meets one of the following conditions:
- Is transferred from an acute care facility reimbursed under the DRG case-based payment system to another acute care facility reimbursed under the same system.
- Is transferred to an out-of-state acute care facility.
- Is a neonate who is being transferred to an exempt hospital for neonatal services.
Hospitals must ensure the accuracy of patient discharge status coding on Medicaid claims.
For additional information regarding:
- NYCRR, Title 10, §86-1.15, and transfer payments (NYCRR, Title 10, Part 86-1.21), providers should refer to the New York State Department of Health (DOH) New York Codes, Rules and Regulations.
- Inpatient billing guidelines, providers should refer to the eMedNY New York State UB-04 Billing Guidelines.
JP# 56284 10/2021