Wiki 23 hr observation in ICU?

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heartyoga

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We are an independent practice from the hospital, so we sometimes have difficulty communicating with hospital if they change the status of patient stay from inpatient to 23 hr observation or vice versa.

We have a case of patient being admitted to ICU chest pains, 10/10, short of breath but enzymes checked to be negative. Patient was admitted on a Friday afternoon so my guess was case management was not able to precert? (with BCBS).

Patient was discharged on a Sunday.

Our physician was under the impression it was an inpatient at ICU (which at the time of service patient was not in good shape). So we billed it service location as Inpatient.

After a week or so, we looked again at hospital site and discovered patient was changed back to 23 hr observation.

Question:

1. Does the 2 midnight rule apply here or it is not a strictly 2 midnight? Patient admitted noon of Friday discharged Sunday afternoon? How come it was still outpatient 23 hr observation on hospital status?
2. We billed/coded (not sent out yet pending clarification with hospital) inpatient visit 99254 Blue Select ? But should we change it to outpatient visit 99245 to match the hospital status?
3. We are debating if we have hold our claims and double check with hospital if they changed status from OP to IP or vice versa before submitting our claims?
(Too much work but if necessary will do it)

Has anybody experienced this? Suggestions?

Thanks!
 
The organization I code for deals with this all the time, and if there is an easy solution, I have not yet seen it. Unfortunately, you cannot determine whether a patient is inpatient or observation by the amount of time they spend in the hospital, by what the diagnosis is, when or how the authorization was done, or by what unit they are in. In reality I think it is the payers that dictate this more than anything else. Theoretically, this should be determined by the admitting physician's order, but different payers have different rules and criteria for what they will allow, and sometimes they make this determination in advance and sometimes after the fact. I have seen some payers review records months after the patient has been discharged and make the decision that an inpatient claim should have been billed as observation, so we have to go back and make corrected billings to claims we billed months ago. Our hospital has a communication set up so that whenever a status is changed, a message goes out to everyone who needs to know and then the corrections can be made by all of the responsible areas. I would imagine that the hospitals you work with must have some process like that, so perhaps there is a way that someone in your practice can get added to those distribution lists? Other than staying in touch with the hospital and being advised promptly whenever a status is updated, I don't know of any other way to avoid this particular kind of inconvenience that the payers impose.
 
Last edited:
heartyoga said:
We are an independent practice from the hospital, so we sometimes have difficulty communicating with hospital if they change the status of patient stay from inpatient to 23 hr observation or vice versa.

We have a case of patient being admitted to ICU chest pains, 10/10, short of breath but enzymes checked to be negative. Patient was admitted on a Friday afternoon so my guess was case management was not able to precert? (with BCBS).

Patient was discharged on a Sunday.

Our physician was under the impression it was an inpatient at ICU (which at the time of service patient was not in good shape). So we billed it service location as Inpatient.

After a week or so, we looked again at hospital site and discovered patient was changed back to 23 hr observation.

Question:

1. Does the 2 midnight rule apply here or it is not a strictly 2 midnight? Patient admitted noon of Friday discharged Sunday afternoon? How come it was still outpatient 23 hr observation on hospital status?
2. We billed/coded (not sent out yet pending clarification with hospital) inpatient visit 99254 Blue Select ? But should we change it to outpatient visit 99245 to match the hospital status?
3. We are debating if we have hold our claims and double check with hospital if they changed status from OP to IP or vice versa before submitting our claims?
(Too much work but if necessary will do it)

Has anybody experienced this? Suggestions?

Thanks!
Click to expand...

Hello,

I don't think the two midnight rule applies here if the patient isn't insured under MCR or had the documented medical necessity as to why they were placed under Observation from Friday afternoon to Sunday afternoon.

I would definitely check the status (Observation/Inpatient) with the hospital before billing out to avoid a denial from the payor. If they were Observation and the documentation supports CPT 99245 then okay to bill.


M.Hannus, CPC, CPMA, CRC
 
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