TECHNICAL NOTES APPENDIX SUMMER

Transcription

1 TECHNICAL NOTES APPENDIX SUMMER Hospital Performance Report Summer Update INCLUDES PENNSYLVANIA INPATIENT HOSPITAL DISCHARGES FROM JULY 1, 2006 THROUGH JUNE 30, 2007 The Pennsylvania Health Care Cost Containment Council June 2008

2 Pennsylvania Health Care Cost Containment Council 225 Market Street, Suite 400 Harrisburg, PA Phone: (717) Fax: (717) David H. Wilderman, Acting Executive Director

3 TABLE OF CONTENTS Preface...i Definition Tables Table A. The 31 Code-Based Conditions/Procedures and 20 DRGs in the Hospital Performance Report Summer Update... A-1 Table B. ICD-9-CM Codes Used to Define Readmissions for Complication or Infection. A-3 Data Tables Table C. Statewide Utilization and Outcome Data 1. Code-Based Conditions... A-4 2. DRGs... A-5 Table D. Statewide Cases Readmitted for Complication or Infection, by Reason for Readmission 1. Code-Based Conditions... A-6 2. DRGs... A-7 Table E. Statewide Exclusions from Analyses, By Measure 1. Code-Based Conditions... A-8 2. DRGs... A-9 Table F. Hospitals Not Reported in the Hospital Performance Report Summer Update A-10 Table G. Valid Discharge Status Codes... A-11 PREFACE The Technical Notes Appendix Summer in conjunction with the Technical Notes that accompanied the FFY 2006 Hospital Performance Report (HPR) provide important information regarding the analysis and development of the Hospital Performance Report Summer Update (July 1, 2006 through June 30, 2007 data). The full Technical Notes describes the methodology of the analyses and outlines the development of the report format and presentation. The Technical Notes Appendix - Summer includes tables that: 1) describe the code-based conditions and DRGs in the report, 2) define readmissions for a complication or infection, 3) display statewide results, 4) categorize all cases readmitted for a complication or infection by specific reasons, 5) present cases that were excluded from analyses, 6) list hospitals excluded from the report, and 7) list valid discharge status codes. These tables contain information that is relevant to the current study period (i.e., Q through Q2-2007). Additional Information: ICD-9-CM codes and DRGs used in the HPR Summer Update are applicable to CMS Grouper Versions 23 and 24. To ensure the integrity of the risk-adjustment models, ratings are not reported when the volume of measured events statewide is less than ten (after exclusions). For example, mortality ratings are not reported for code-based conditions or DRGs with less than ten mortalities statewide. Additionally, ratings for code-based conditions or DRGs with events statewide are based on the first risk factor alone (i.e., Atlas Outcomes predicted probability of death or predicted length of stay, depending on the measure; refer to the full Technical Notes for details). When the number of measured events exceeds 29, risk adjustment models are based on all three risk factors. i

4 In Tables E1 & E2 (Statewide Exclusions from Analysis, by Measure), intermediary hospitalizations are subsequent admissions within 30 days for the same hospital and condition, with a mutually eligible readmission for complication or infection. Intermediary hospitalizations are excluded from the readmission analysis. Transfer-out records are defined as discharge status 02, 43, 63 and 66. See Table G (Valid Discharge Status Codes) for descriptions of discharge status codes. For the readmissions analyses, same day readmissions include records with discharge status 01 and 06 only. See Table G (Valid Discharge Status Codes) for descriptions of discharge status codes. Patients transferred to acute care facilities (short-term, long-term, or federal hospital; discharge status codes 02, 43, 63, 66) are excluded from all analyses except the Transfer to Acute Care percent (reported for Heart Attack Medical Management only). The Hospital Performance Report Summer Update utilizes Atlas Outcomes version 4.0 scoring algorithms. DRG 571-Major Esophageal Disorders was added to the definition of Stomach and Intestinal Bleeding beginning with the 2006 Hospital Performance Report Spring Update. A new condition Kidney Failure Acute replaced the old condition Kidney Failure beginning with the 2006 Hospital Performance Report Winter Update. Kidney Failure Acute: A sudden and rapid loss of kidney function resulting in a build-up of waste products that are normally removed from the body through urine. Because these waste products are toxic, acute kidney failure can be lifethreatening. Acute kidney failure may be caused by trauma, surgery, dehydration, medication or other conditions. ii

5 TABLE A The 31 Code-Based Conditions/Procedures and 20 DRGs in the Hospital Performance Report Summer Update The following table outlines the code-based conditions and procedures (the ICD-9-CM codes and DRGs used to define each medical condition or surgical procedure) and the DRGs included in this report (inpatient discharges from July 1, 2006 through June 30, 2007). These codes and DRGs are applicable to CMS Grouper Versions 23 and 24. Additional exclusions (clinically complex cases) are identified as footnotes. The 19 code-based medical conditions are: Medical Condition 1 Principal Diagnosis Codes (ICD-9-CM) DRGs Abnormal Heartbeat 426.0, , , , , 426.2, 426.3, 426.4, , , , , , 426.6, 426.7, , , , 426.9, 427.0, 427.1, 427.2, , , , , , , , 427.9, , Blood Clot in Extremities 451.0, , , 451.2, , , , , , 451.9, , , , 453.8, Blood Clot in Lung , , 118, 124, 125, 138, 139, 518, 552, 556, ,130,131 Chronic Obstructive Pulmonary , , , 492.0, 492.8, 496, Disease Congestive Heart Failure (CHF) , 428.0, 428.1, , , , , , , , , , , , , 127 Diabetes with Amputation 250.xy (x = 0-9, y = 0-3) 113, 114, 285 Diabetes Medical Management 250.xy (x = 0-9, y = 0-3) 018, 019, 130, 131, 294, 295, 331, 332 Heart Attack Medical Management , , , , , , , , , ,122,123 Intestinal Obstruction 560.0, 560.2, , , , , , , 181 Kidney Failure Acute 584.5, 584.6, 584.7, 584.8, Kidney and Urinary Tract Infections , , , , 590.2, 590.3, , 590.9, 595.x (x = 0-3), , , 595.9, , 321 Pneumonia Aspiration , 080 Pneumonia Infectious 480.0, 480.1, 480.2, 480.3, 480.8, 480.9, 481, 482.0, 482.1, 482.2, , , , , , , , , , , , , 482.9, 483.0, 483.1, 483.8, 485, 486, Respiratory Failure with Mechanical Ventilation Respiratory Failure without Mechanical Ventilation 079, 080, 089, , 518.5, , , , 565 3, , 518.5, , , Septicemia 038.0, , , , 038.2, 038.3, , , , , , , 038.8, 038.9, , , , , Stomach and Intestinal Bleeding 456.0, 530.7, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 569.3, , Stroke Hemorrhagic 430, 431, 432.0, 432.1, , 575 3, , 175, Stroke Non-Hemorrhagic , , , , , , , , , , 015, Cases with HIV Infections (ICD-9-CM code 042, in any position) were excluded from all code-based conditions and procedures. 2 Invalid as of October 1, Valid as of October 1, DRG 571 was added beginning with the 2006 Hospital Performance Report Spring Update. A-1

6 TABLE A CONTINUED The 12 code-based surgical procedures are: Surgical Procedures 1 Principal Procedure Codes (ICD-9-CM) DRGs Abdominal Aortic Aneurysm Repair - Endovascular Abdominal Aortic Aneurysm Repair - Open With principal diagnosis (PDx) of , 38.64, With PDx of Colorectal Procedures , 45.72, 45.73, 45.74, 45.75, 45.76, 45.79, 45.8, 45.92, 45.94, 46.03, 46.10, 46.11, 46.13, 46.42, 46.43, 46.52, 46.76, 46.94, 48.49, 48.5, 48.62, 48.63, 48.69, 48.75, 48.76, , , , 147, 148 3, 149, 569 4, Gallbladder Removal - Laparoscopic 51.23, , 196, 493, 494 Gallbladder Removal - Open 51.21, , 196, 197, 198 Heart Attack - Angioplasty/Stent 00.66, 36.06, With PDx of , , , , , , , , , or Hip Fracture - Surgical Repair 78.55, 79.15, 79.25, 79.35, 79.55, 81.51, With PDx of 820.0x (x = 0 3,9), 820.1x (x = 0 3,9), 820.2x (x = 0 2), 820.3x (x = 0 2), 820.8, or , , 211, 544 Hysterectomy - Abdominal 68.31, 68.39, , , , , , , , 354, 355, 357, 358, 359 Hysterectomy - Vaginal 68.51, 68.59, , , , 354, 355, 357, 358, 359 Prostatectomy - Radical 60.3, 60.4, 60.5, 60.62, , 307, 334, 335 Prostatectomy - Transurethral 60.21, , 307, 334, 335, 336, 337 Removal of Blockage of Neck Vessels , 534 The 20 DRGs reported are: DRG Common Names 001 Brain Surgery, complicated 075 Major Lung Operations 076 Miscellaneous Lung Procedures, complicated 096 Bronchitis and Asthma, complicated 097 Bronchitis and Asthma, uncomplicated 141 Hypotension and Fainting, complicated 143 Chest Pain 154 3, 567 4, Stomach and Small Intestinal Operations, complicated 182 Stomach and Intestinal Infections and Disorders, complicated 183 Stomach and Intestinal Infections and Disorders, uncomplicated 188 Stomach and Intestinal Complications and Disorders 202 Cirrhosis and Alcoholic Hepatitis 203 Liver, Gallbladder or Pancreatic Cancer 204 Noncancerous Pancreatic Disorders 205 Liver Disease Except Cancer, Cirrhosis, Alcoholic Hepatitis, complicated 243 Medical Back Problems 415 3, 578 4, Surgery for Infectious or Parasitic Disease 418 Infection after Surgery or Trauma 553 Vascular Operations Excluding Heart, complicated, with Major Cardiovascular Condition 554 Vascular Operations Excluding Heart, complicated, without Major Cardiovascular Condition 1 Cases with HIV Infections (ICD-9-CM code 042, in any position) were excluded from all code-based conditions and procedures. 2 Cases with abdominal trauma were excluded. Abdominal trauma was defined by the following ICD-9-CM codes: , , , , 908.1, 908.2, 908.4, 908.6, 908.9, 922.2, 935.2, 936, 937, 938, or Invalid as of October 1, Valid as of October 1, A-2

7 TABLE B ICD-9-CM Codes Used to Define Readmissions for Complication or Infection Readmissions with one of the following ICD-9-CM codes listed as the principal diagnosis or principal procedure were included in this measure. These codes are applicable to CMS Grouper Versions 23 and 24. ICD-9-CM Codes Diagnosis/Procedure ICD-9-CM Codes Diagnosis/Procedure Procedure/Medical Care Related Events Cardiac Complications (procedure) Venous Thrombosis/Pulmonary Embolism Digestive System Complications Hypotension/Hypertension Pulmonary Compromise Stroke/Anoxic Brain Damage 31.1 (procedure) (procedure) (procedure) Hemorrhage (procedure) (procedure) (procedure) Device, Implant or Graft Complications Infection Gastric/Intestinal Ulceration with Hemorrhage or Perforation (procedure) Pneumonia (coded by causative organism) A-3

8 TABLE C1 Statewide Utilization and Outcome Data for Code-Based Conditions Description Medical Conditions # of % Cases 1 Mortality 2 Length of Stay 2 Readmissions % Any Reason 2 % Comp/ Infec 2 Average Charge 2 Abnormal Heartbeat 39, $27,310 Blood Clot in Extremities 7, NR NR $16,585 Blood Clot in Lung 7, NR NR $27,957 Chronic Obstructive Pulmonary Disease 27, $21,057 Congestive Heart Failure 52, $25,473 Diabetes with Amputation 2, $62,070 Diabetes - Medical Management 17, $20,099 Heart Attack - Medical Management 12, NR NR $32,135 Intestinal Obstruction 8, NR NR $19,853 Kidney Failure - Acute 19, $28,264 Kidney and Urinary Tract Infections 22, $19,778 Pneumonia - Aspiration 9, $31,584 Pneumonia - Infectious 41, $23,430 Respiratory Failure with Mechanical Ventilation Respiratory Failure without Mechanical Ventilation 6, $72,920 8, $29,118 Septicemia 23, NR NR $39,435 Stomach and Intestinal Bleeding 20, $23,514 Stroke - Hemorrhagic 3, $40,001 Stroke - Non-Hemorrhagic 19, $30,048 Abdominal Aortic Aneurysm Repair - Endovascular Abdominal Aortic Aneurysm Repair - Open Surgical Procedures 1,511 NR $88, $80,040 Colorectal Procedures 14, NR NR $61,756 Gallbladder Removal - Laparoscopic 14, $30,380 Gallbladder Removal - Open 2, $48,508 Heart Attack - Angioplasty/Stent 12, NR NR $67,861 Hip Fracture - Surgical Repair 13, $39,685 Hysterectomy - Abdominal 15,686 NR 2.7 NR NR $23,776 Hysterectomy - Vaginal 7,017 NR $18,268 Prostatectomy - Radical 3,702 NR 2.6 NR NR $37,501 Prostatectomy - Transurethral 3,753 NR 2.6 NR NR $17,856 Removal of Blockage of Neck Vessels 5, $27,051 1 Number of cases after mortality exclusions (or LOS exclusions for conditions in which mortality is not reported). 2 Value shown is based on records after all relevant exclusions are removed. NR: Not Reported A-4

9 TABLE C2 Statewide Utilization and Outcome Data for DRGs Readmissions DRG Description # of % Cases 1 Mortality 2 Length of Stay 2 % Any Reason 2 % Comp/ Infec 2 Average Charge Brain Surgery, complicated 3, NR NR $110, Major Lung Operations 5, NR NR $71, Miscellaneous Lung Procedures, complicated 4, NR NR $65, Bronchitis and Asthma, complicated 6,912 NR $19, Bronchitis and Asthma, uncomplicated 5,770 NR $14, Hypotension and Fainting, complicated 13, $19, Chest Pain 38,939 NR $16, , Stomach and Small Intestinal Operations, 567 4, complicated 3, NR NR $101, Stomach and Intestinal Infections and Disorders, complicated Stomach and Intestinal Infections and Disorders, uncomplicated Stomach and Intestinal Complications and Disorders 32, NR NR $19,215 17,557 NR 2.5 NR NR $15,821 9, NR NR $24, Cirrhosis and Alcoholic Hepatitis 4, $36, Liver, Gallbladder or Pancreatic Cancer 3, NR NR $36, Noncancerous Pancreatic Disorders 9, $22, Liver Disease Except Cancer, Cirrhosis, Alcoholic Hepatitis, complicated 4, $34, Medical Back Problems 12, $19, , Surgery for Infectious or Parasitic 578 4, Disease 6, $80, Infection after Surgery or Trauma 4, $24, Vascular Operations Excluding Heart, complicated, with Major Cardiovascular Condition Vascular Operations Excluding Heart, complicated, without Major Cardiovascular Condition 3, NR NR $81,992 6, NR NR $52,961 1 Number of cases after mortality exclusions (or LOS exclusions for DRGs in which mortality is not reported). 2 Value shown is based on records after all relevant exclusions are removed. 3 Invalid as of October 1, Valid as of October 1, NR: Not Reported A-5

10 TABLE D1 Statewide Cases Readmitted for Complication or Infection, by Reason for Readmission Code-Based Conditions Code-Based Condition # of Cases Meeting Readmissions Criteria Total # of Cases Readmitted for Complication or Infection % of Cases Readmitted for Complication or Infection Procedure/Medical Care Related Events Digestive System Complications Pulmonary Compromise Hemorrhage REASON FOR READMISSION Infection Pneumonia Cardiac Complications Venous Thrombosis/ Pulmonary Embolism Hypo/Hypertension Stroke/Anoxic Brain Damage Device, Implant or Graft Complications Gastric/Intestinal Ulceration w Hemorrhage or Perforation Medical Conditions Abnormal Heartbeat 36, Chronic Obstructive Pulmonary Disease 26,274 1, Congestive Heart Failure 48,003 2, Diabetes with Amputation 2, Diabetes - Medical Management 16, Kidney Failure - Acute 16,686 1, Kidney and Urinary Tract Infections 21, Pneumonia - Aspiration 7, Pneumonia - Infectious 38,589 2, , Respiratory Failure with Mechanical Ventilation Respiratory Failure without Mechanical Ventilation Stomach and Intestinal Bleeding 3, , , Stroke - Hemorrhagic 2, Stroke - Non-Hemorrhagic 17,093 1, Abdominal Aortic Aneurysm Repair - Endovascular Abdominal Aortic Aneurysm Repair - Open Gallbladder Removal - Laparoscopic Surgical Procedures 1, , Gallbladder Removal - Open 2, Hip Fracture - Surgical Repair 12, Hysterectomy - Vaginal 6, Removal of Blockage of Neck Vessels 4, Note: For some conditions, the sum of the readmits for complication or infection may be higher than the total because some records have both a principal diagnosis and a principal procedure that meet the criteria for being captured in this analysis. When this occurs, the record is shown in each readmission category; however, the record is counted only once in determining the percent of readmissions for complication or infection. A-6

11 TABLE D2 Statewide Cases Readmitted for Complication or Infection, by Reason for Readmission DRGS DRG # of Cases Meeting Readmissions Criteria Total # of Cases Readmitted for Complication or Infection % of Cases Readmitted for Complication or Infection Procedure/Medical Care Related Events Digestive System Complications Pulmonary Compromise Hemorrhage REASON FOR READMISSION Infection Pneumonia Cardiac Complications Venous Thrombosis/ Pulmonary Embolism Hypo/Hypertension Stroke/Anoxic Brain Damage Device, Implant or Graft Complications Gastric/Intestinal Ulceration with Hemorrhage or Perforation Bronchitis and Asthma, complicated Bronchitis and Asthma, uncomplicated Hypotension and Fainting, complicated 6, , , Chest Pain 37, Cirrhosis and Alcoholic Hepatitis Noncancerous Pancreatic Disorders Liver Disease Except Cancer, Cirrhosis and Alcoholic Hepatitis, complicated 3, , , Medical Back Problems 11, / / Surgery for Infectious or Parasitic Disease 5, Infection After Surgery or Trauma 4, Note: For some DRGs, the sum of the readmits for complication or infection may be higher than the total because some records have both a principal diagnosis and a principal procedure that meet the criteria for being captured in this analysis. When this occurs, the record is shown in each readmission category; however, the record is counted only once in determining the percent of readmissions for complication or infection. 1 Invalid as of October 1, Valid as of October 1, 2006 A-7

12 TABLE E1 Statewide Exclusions from Analyses, by Measure Code-Based Conditions The exclusions are listed in the order in which they were removed from the reference database. Mortality Length of Stay Length of Stay Outliers: Short and Long Readmissions: Any Reason and Complication or Infection Average Charge Transfer to Acute Care 5 # % # % # % # % # % # % Total Cases Before Exclusions 437, , , , , , Exclusions: Records with errors Duplicate records <0.1 8 <0.1 Discharge date not in time period Missing or invalid discharge status 26 < < < < <0.1 1 <0.1 Non-adult (< 18) or invalid age 3, , , , , <0.1 Patients with HIV Infection Patients with abdominal trauma 2 55 < <0.1 NA NA NA NA 55 <0.1 NA NA Patients who left against medical advice Patients transferred to GAC facilities 3, , , , , , , , , , NA NA Patients who died NA NA 18, , , NA NA 1, Missing Atlas Outcomes data 3 4, , , , NA NA NA NA Invalid length of stay NA NA 1 <0.1 1 <0.1 1 <0.1 NA NA NA NA Length of stay outliers NA NA 3, NA NA 2, NA NA NA NA Non-Pennsylvania residents NA NA NA NA NA NA 9, NA NA NA NA Patients discharged to hospice NA NA NA NA NA NA 4, NA NA NA NA Missing or inconsistent patient NA NA NA NA NA NA 1, NA NA NA NA identifiers 4 Admit, discharge, readmission date discrepancies NA NA NA NA NA NA NA NA NA NA Invalid charges NA NA NA NA NA NA NA NA NA NA Charge outliers NA NA NA NA NA NA NA NA 10, NA NA No reference data NA NA NA NA NA NA NA NA 1, NA NA Intermediary Hospitalization NA NA NA NA NA NA NA NA NA NA Total Exclusions 25, , , , , , Total Cases in Analysis 411, , , , , , This exclusion is only applicable to the code-based conditions. 2 This exclusion is only applicable to Colorectal Procedures. 3 Missing either MQPredDeath or MQPredLOS, depending on which one is used as a risk adjustor (MQPredDeath was used for mortality and Readmissions for Complication or Infection; MQPredLOS was used for Length of Stay, Length of Stay Outliers, and Readmissions for Any Reason). 4 Social Security Number, Date of Birth, Sex 5 This measure is reported only for Heart Attack Medical Management NA: Not Applicable A-8

13 TABLE E2 Statewide Exclusions from Analyses, by Measure DRGs The exclusions are listed in the order in which they were removed from the reference database. Mortality Length of Stay Length of Stay Outliers: Short and Long Readmissions: Any Reason and Complication or Infection Average Charge # % # % # % # % # % Total Cases Before Exclusions 136, , , , , Exclusions: Records with errors Duplicate records Discharge date not in time period 2 <0.1 2 < <0.1 2 <0.1 Missing or invalid discharge status 4 <0.1 5 < <0.1 Non-adult (< 18) or invalid age 1, , , , Patients who left against medical advice Patients transferred to GAC facilities 1, , , , , , , , , , Patients who died NA NA 3, , NA NA Missing Atlas Outcomes data 1 1, , , NA NA Invalid length of stay NA NA NA NA Length of stay outliers NA NA 1, NA NA NA NA Non-Pennsylvania residents NA NA NA NA NA NA 3, NA NA Patients discharged to hospice NA NA NA NA NA NA NA NA Missing or inconsistent patient NA NA NA NA NA NA 1, NA NA identifiers 2 Admit, discharge, readmission date discrepancies NA NA NA NA NA NA NA NA Invalid charges NA NA NA NA NA NA NA NA Charge outliers NA NA NA NA NA NA NA NA 4, No reference data NA NA NA NA NA NA NA NA Intermediary Hospitalization NA NA NA NA NA NA 50 <0.1 NA NA Total Exclusions 8, , , , , Total Cases in Analysis 128, , , , , Missing either MQPredDeath or MQPredLOS, depending on which one is used as a risk adjustor (MQPredDeath was used for mortality and Readmissions for Complication or Infection; MQPredLOS was used for Length of Stay, Length of Stay Outliers, and Readmissions for Any Reason). 2 Social Security Number, Date of Birth, Sex NA: Not Applicable A-9

14 TABLE F Hospitals Not Reported in the Hospital Performance Report Summer Update The study population for the Hospital Performance Report Summer Update included useable discharge records from all GAC/SGAC Pennsylvania facilities required to abstract clinical data (Atlas) in the reported time period. During the study period there were 176 facilities in Pennsylvania. Hospital Name Reason for Not Reporting Facilities currently in operation that submitted incomplete data 1 : None Facilities for which average charge will not be reported 2 : Southeastern Pennsylvania Memorial York Facilities that closed: Southeastern Pennsylvania Records with data errors Graduate Closed facility effective 03/31/07 Temple University Children s Closed facility effective 12/01/07 Warminster Closed facility effective 10/01/07 Other facilities not reported: Southeastern Pennsylvania Cancer Treatment Centers of America Children s Hospital Philadelphia Children s hospital 3 Coordinated Health Orthopedic DSI of Bucks County St. Christopher s Children s Children s hospital 3 New facility required to submit UB and Atlas data beginnning10/01/06 not enough data for analysis New facility required to submit UB and Atlas data beginning Q4, 2007 not enough data for analysis New facility required to submit UB and Atlas data beginning Q1, 2008 not enough data for analysis Surgical Institute of Reading New facility required to submit UB and Atlas data beginning Q1, 2008 not enough data for analysis Western Pennsylvania Children s Hospital Pittsburgh Children s hospital 3 Edgewood Specialized hospital number of records available for analysis in HPR was negligible 4 1 Noncompliant hospitals with 10% missing Atlas Outcomes severity scores (based on all records for which severity scores are required to be reported) or facilities that submitted incomplete UB data for one or more quarters. 2 Discharges relevant to the charge analysis were excluded from the statewide dataset. 3 Children s hospitals were not reported because pediatric cases were excluded from the Hospital Performance Report. However, adult discharges from pediatric hospitals were retained in the statewide dataset. 4 Discharges relevant to the HPR were retained in the statewide dataset. A-10

15 TABLE G Valid Discharge Status Codes Code Description 01 Discharged to home or self-care (routine discharge) 02 Discharged/transferred to another short-term general hospital for inpatient care 03 Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification 04 Discharged/transferred to an intermediate care facility (ICF) 05 Discharged/transferred to another type of institution not defined elsewhere in this code list 06 Discharged/transferred to home under care of organized Home Health Service Organization in anticipation of covered skilled care 07 Left against medical advice (AMA) or discontinued care 20 Expired 43 Discharged/Transferred to a Federal health care facility 50 Discharged to Hospice home 51 Discharged to Hospice medical facility 61 Discharged/transferred to hospital-based Medicare approved swing bed 62 Discharged/transferred to an inpatient rehabilitation facility including rehabilitation distinct part units of a hospital 63 Discharged/transferred to a Medicare certified long term care hospital (LTCH) 64 Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare 65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital 66 Discharged/transferred to a Critical Access Hospital A-11