Condition code 42

When a patient is discharged home with home health services, can we report condition code 42 on the claim when the principal diagnosis on the inpatient claim is not the same reason the patient will be receiving home care? For example, a diabetic patient was admitted to the hospital for sepsis and developed a decubitus ulcer on her heel. The patient was discharged home 3 days after admission with home health for the decubitus ulcer and the home care began the day after discharge. If we report condition code 42 on the claim, would the post-acute transfer policy still apply?

Comments

  • You would only report condition code (CC) 42 when the home health care is unrelated to the hospital stay in general. Using CC42 is not about matching the principal diagnosis for the acute care stay to the primary reason for the home health care. In the example of sepsis with the decubitus ulcer requiring home health after discharge, care for the decubitus would be related to the acute care stay because the patient did receive treatment for it. The reduction in payment will only apply when the actual length of stay (LOS) is less than the geometric mean LOS (GMLOS) for that DRG and the DRG is identified in Table 5 as part of post-acute transfer (PACT) policy. CC42 would prevent the reduction in payment, if applicable. Refer to MLN Matters SE1411 and the UB04 Manual definition of condition code 42 for more guidance.

  • I will add that this issue was posted as a target for Recovery Audit contractors but then was pulled off. I had discussed it on RACMonitor.com and brought attention to the complexity of the issue. 
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