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An important element in the American Heart Association’s, “Get with the Guidelines-Stroke“ is that tPA should be administered within 4.5 hours of the first sign of stroke to dissolve the blood clot, restore blood flow to the impacted area of the brain and reduce disability.

 

“Drip and ship” means that front-line, community hospitals quickly administer tPA to people suffering an ischemic stroke, and then immediately transport them to a comprehensive stroke center.

 

The front-line community hospital typically treats the patient in the Emergency Department, administers tPA and prepares the patient for transport. The community hospital will bill an outpatient ED claim including the HCPCS code for the tPA (J2997- Injection, alteplase recombinant, 1 mg), CPT codes for the administration of the bolus/infusion of the tPA and any additional services provided prior to transfer.

 

The receiving hospital will admit the patient and assume responsibility for the patient’s care.

 

Upon discharge, the hospital will bill the admission on an inpatient claim.

 

In addition to services provided while an inpatient, the receiving hospital should also add ICD-10-CM code Z92.82 (Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility) as a secondary diagnosis.  Including this code on the inpatient claim increases the reimbursement for the admission (in addition to the DRG payment). CMS coding guidance indicates that this code should be added even if the patient is still receiving the tPA at the time they are admitted to the receiving facility.

 

Due to the specificity of the code, we recommend the transfer record be included in the medical record of the inpatient admission and that it is review to ensure that the documentation details that the patient received the tPA within 24 hours of admission.

 

It may be difficult to identify these patients since the tPA was not administered at the receiving facility, and therefore J2997 would not be listed on the account. One approach is to review all inpatient discharges with a Point of Origin Code = 4 (Transfer from a hospital (different facility); Inpatient-The patient was admitted to this facility as a hospital transfer from an acute care facility where he or she was an inpatient or outpatient) that also have an ICD-10-CM diagnosis code of Stroke. Point of Origin codes are a required data field on the UB-04 or 837I (electronic equivalent of UB-04).

 

SHOUT-OUTS!

 

1. Revenue Cycle and HIM should develop a process to identify inpatient stroke patients who received tPA and another acute-care facility prior to transfer. One approach is to review all claims with a Point of Origin Code = 4, and a ICD-10-CM Diagnosis code of Stroke.

2. HIM Coders should review the transfer record to ensure that there is documentation that the patient received tPA at the originating facility and add ICD-10-CM code Z92.82 as a secondary diagnosis which results in additional reimbursement.