Wiki Billing OP Services IP for 72 Hour Rule

[Agilbert3]

Hello all,
I am a new coder and trying to find answers for myself and our billing department.

I understand that for Medicare patients who are rendered services such as x-rays and labs in outpatient setting then admitted inpatient within DRG window, that those services are bundled with inpatient services.

Our question is how do we do that? Do I code those services as a charge to the hospital? Or does the biller abstract the information and do it herself (this is our hospital biller, not our clinic biller asking)?

For patients listed as admit, we have been omitting any E/M codes, but still charging the labs and X-rays to our own clinic. My partner coder and I had been thinking they did this on their end, but they don't seem too sure of the proper way either.

Any advice for me and our billing dept? This is not my area of understanding.

 

[thomas7331]

I'd have to ask first if you are coding for an independent practice, or for a hospital satellite department. If you are a separate entity from the hospital, you should not have to do anything differently as the 72-hour rule only bundles payments provided by entities that are 'wholly owned or wholly operated' by the hospital to which the patient was admitted. Services provided by outside entities, in most cases, are not part of the DRG payment. If you are not part of the hospital, then you should not code your claims any differently based on the fact that the patient was admitted within 72 hours.

If your clinic is part of the hospital system, on the other hand, then your hospital's billing department should have a system in place of this and should be instructing you on the proper way to do this. Physician professional services are not affected by this, but the facility fees and charges for any labs or technical components will need to be rolled into the inpatient claim. In cases where you have coded a global service, the charge may need to be split so that the professional service is billed to Part B and the technical is added to the inpatient claim. In the hospital where I worked, the software would flag these situations for the billing department once all of the charges were coded, and the billers would perform this function - it is not really a job that requires a coder training because all CPT codes are dropped from the inpatient claim and it is just a matter of consolidating all of the charges onto a single claim. But the process for this can vary greatly depending on how the hospital billing system and software is set up and also by the provider-based status of the hospital clinics, and the rules can vary as to what services should or should not be included and by the type of facility or admission, so there is no 'one-size-fits-all' formula for how to do this. It seems odd that they would not be able to tell you how this is handled, but perhaps you just need to speak to the right person of find the supervisor or manager at the facility who oversees this to get more information.

 

[Agilbert3]

Thank You

This has been very informative. Thank you. Yes, we are a rural health clinic owned by the hospital. Our CPT/ HCPCS codes have item numbers directing them to post to either clinic or hospital accounts. We use the hospital item numbers for our physicians' hospital visits.

I was able to to clarify more with the hospital biller, and it seems they do have a process for claims consolidation, but are wondering if we could start posting the services to the hospital's account number to expedite the process.

My thought it no, as it is still important to post codes to the correct place of service. I'm still new at this, but I think this skews reporting data, regardless of who gets paid.

 

[Birdie625]

So Thomas can I inquire as well re: the Pro-fee portion. We are provider-based. Our system auto-combines 72-hr charges into the IP encounter....before any coding has been done to any encounter. I do the ortho pro-fee (1500 clm) only; Ortho saw pt in ER on 24th (codes should be an e/m-25 and proc. was a/10-day global); f/up in clinic 2-days later (26th w/po 99024) and at that time the Dr decides to do an admit to IP d/t diagnosis (same dx as ER visit).

How do the Ortho charges for the ER 24th visit get billed? Is it because we are provider-based these pro-fee charges get put to the IP encounter (but on a 1500 claim). What about the DOS mismatch (ER=24 // IP = 26 to___). And d/t the 10-day global of ER procedure, the IP admit would be global as well (any further proc. will have an appropriate modifier(s)).

Any further info you can provider is greatly appreciated; or links to material; I have found a CMS MLN FAQ on such, but do need to spend more time reading/comprehending such. Thank you much.

 

[thomas7331]

So Thomas can I inquire as well re: the Pro-fee portion. We are provider-based. Our system auto-combines 72-hr charges into the IP encounter....before any coding has been done to any encounter. I do the ortho pro-fee (1500 clm) only; Ortho saw pt in ER on 24th (codes should be an e/m-25 and proc. was a/10-day global); f/up in clinic 2-days later (26th w/po 99024) and at that time the Dr decides to do an admit to IP d/t diagnosis (same dx as ER visit).

How do the Ortho charges for the ER 24th visit get billed? Is it because we are provider-based these pro-fee charges get put to the IP encounter (but on a 1500 claim). What about the DOS mismatch (ER=24 // IP = 26 to___). And d/t the 10-day global of ER procedure, the IP admit would be global as well (any further proc. will have an appropriate modifier(s)).

Any further info you can provider is greatly appreciated; or links to material; I have found a CMS MLN FAQ on such, but do need to spend more time reading/comprehending such. Thank you much.

If you are coding professional services performed in a facility, you do not have to worry about the 72-rule as that applies only to facility fees. Professional fees with a facility place of service are reimbursed on the physician fee schedule at the facility rate, which is an entirely separately and independent payment system from the DRG. Your place of service should correspond to the patient's location and status at the time of service, so if the patient was seen in the ED, use the ED E/M codes.