Wiki Coding for Self Pay patients

[Strumble]

Hi,
I'm not an inpatient coder but I do need help in understanding this issue. I have a self pay patient who was given an itemized bill, including labs, meds, imaging, or room and pacu, etc. I believe inpatient coding is based on a PCS code, which should be one facility charge, correct?

I requested a coding review and DRG comparison pricing. Originally, the surgeon had incorrectly coded for the procedure after the surgeon corrected the code, billing is telling me there is no change to amount due because time is what determines the OR charge. I think it's a component but not determinate in charges.

Can someone help me understand this please? Is coding different for self-pay patients? Can they be charged per item instead of PCS or DRG? Attached is the bill in case I'm not making sense. Thank you!

 

[thomas7331]

For inpatient facility claims, coding and charges are two separate things - it's not like physician coding where every code has a specific charge. On a hospital claim, the charges are based on facility resource utilization - all of the items you mention above, plus things like drugs, supplies, meals, use of specific services, many of which do not have any specific code. And if a surgery is performed during the stay, the hospital will charge based on the use of the operating room by time, or level of complexity, and not necessarily according to the specific type of procedure that was performed there, although different facilities handle this differently.

The coding for an inpatient claim, on the other hand, will be a reporting of the diagnosis and PCS procedure codes which related to the patient's care during the hospitalization, and these do not affect the charges on the claim in any way. If the payer's contract reimburses the hospital based on DRG, then the payer will use the codes to identify the correct DRG code and reimburse the hospital based on that rate, not based on how much is charged. However, some insurance contracts may have different reimbursement methods, and may pay the hospital, for example, a percentage of the charges billed or a per diem rate rather than using the DRG. It all depends on what that hospital has negotiated with that particular insurance company.

The charges and coding will not be affected in any way by whether the patient is self pay or insured. However, since self pay patients do not have an insurance plan that has a negotiated rate in place for the services they've received, they are just responsible for the bill itself.

Looking at the itemized bill you've attached, it looks to me a bit high but not inappropriately so, and it's not too different from what other facilities I've worked with would charge. It appears that they have given the patient a 25% discount off of the total billed charges, which may be that facility's policy for self pay patients to bring the charges more in line with what other insurance contracts would pay for a similar service. But again, the diagnosis or PCS coding would not change any of what was charged though.

 

[sls314]

Hi,
I'm not an inpatient coder but I do need help in understanding this issue. I have a self pay patient who was given an itemized bill, including labs, meds, imaging, or room and pacu, etc. I believe inpatient coding is based on a PCS code, which should be one facility charge, correct?

I requested a coding review and DRG comparison pricing. Originally, the surgeon had incorrectly coded for the procedure after the surgeon corrected the code, billing is telling me there is no change to amount due because time is what determines the OR charge. I think it's a component but not determinate in charges.

Can someone help me understand this please? Is coding different for self-pay patients? Can they be charged per item instead of PCS or DRG? Attached is the bill in case I'm not making sense. Thank you!

The document you listed is an itemized statement, which is typically what would be given to anyone who wanted to see an itemized list of charges. Payers and auditors sometimes request the itemized statement for an inpatient state. It is appropriate to give a self-pay patient.

Facility claims are billed to payers on a UB-04 claim form. All of the charges on that itemized statement would still be listed on the UB-04, rolled up by revenue code. (Example - all the charges for Revenue 250 would typically be summed up on one line, etc.)

The presence of ICD-10-PCS codes don't change the total billed charges on the claim - PCS codes just provide additional descriptive information for payer processing.

Here's a link to a UB-04 claim form for reference, if you haven't seen one before: https://www.cdc.gov/wtc/pdfs/policies/ub-40-P.pdf

The charges from the itemized statement would be listed in that big middle area on the form (beginning with Box 42 - Revenue Code).

ICD-10-PCS codes would go in the bottom left corner area (starting with Box 74 Principal Procedure). No charges are listed in this area. I can't think of any reason why a self-pay patient would need ICD-10-PCS codes.

 

[Strumble]

For inpatient facility claims, coding and charges are two separate things - it's not like physician coding where every code has a specific charge. On a hospital claim, the charges are based on facility resource utilization - all of the items you mention above, plus things like drugs, supplies, meals, use of specific services, many of which do not have any specific code. And if a surgery is performed during the stay, the hospital will charge based on the use of the operating room by time, or level of complexity, and not necessarily according to the specific type of procedure that was performed there, although different facilities handle this differently.

The coding for an inpatient claim, on the other hand, will be a reporting of the diagnosis and PCS procedure codes which related to the patient's care during the hospitalization, and these do not affect the charges on the claim in any way. If the payer's contract reimburses the hospital based on DRG, then the payer will use the codes to identify the correct DRG code and reimburse the hospital based on that rate, not based on how much is charged. However, some insurance contracts may have different reimbursement methods, and may pay the hospital, for example, a percentage of the charges billed or a per diem rate rather than using the DRG. It all depends on what that hospital has negotiated with that particular insurance company.

The charges and coding will not be affected in any way by whether the patient is self pay or insured. However, since self pay patients do not have an insurance plan that has a negotiated rate in place for the services they've received, they are just responsible for the bill itself.

Looking at the itemized bill you've attached, it looks to me a bit high but not inappropriately so, and it's not too different from what other facilities I've worked with would charge. It appears that they have given the patient a 25% discount off of the total billed charges, which may be that facility's policy for self pay patients to bring the charges more in line with what other insurance contracts would pay for a similar service. But again, the diagnosis or PCS coding would not change any of what was charged though.

Thank you so much, that is very helpful!

 

[Strumble]

The document you listed is an itemized statement, which is typically what would be given to anyone who wanted to see an itemized list of charges. Payers and auditors sometimes request the itemized statement for an inpatient state. It is appropriate to give a self-pay patient.

Facility claims are billed to payers on a UB-04 claim form. All of the charges on that itemized statement would still be listed on the UB-04, rolled up by revenue code. (Example - all the charges for Revenue 250 would typically be summed up on one line, etc.)

The presence of ICD-10-PCS codes don't change the total billed charges on the claim - PCS codes just provide additional descriptive information for payer processing.

Here's a link to a UB-04 claim form for reference, if you haven't seen one before: https://www.cdc.gov/wtc/pdfs/policies/ub-40-P.pdf

The charges from the itemized statement would be listed in that big middle area on the form (beginning with Box 42 - Revenue Code).

ICD-10-PCS codes would go in the bottom left corner area (starting with Box 74 Principal Procedure). No charges are listed in this area. I can't think of any reason why a self-pay patient would need ICD-10-PCS codes.

Thank you! I really appreciate the information.

 

[Strumble]

For inpatient facility claims, coding and charges are two separate things - it's not like physician coding where every code has a specific charge. On a hospital claim, the charges are based on facility resource utilization - all of the items you mention above, plus things like drugs, supplies, meals, use of specific services, many of which do not have any specific code. And if a surgery is performed during the stay, the hospital will charge based on the use of the operating room by time, or level of complexity, and not necessarily according to the specific type of procedure that was performed there, although different facilities handle this differently.

The coding for an inpatient claim, on the other hand, will be a reporting of the diagnosis and PCS procedure codes which related to the patient's care during the hospitalization, and these do not affect the charges on the claim in any way. If the payer's contract reimburses the hospital based on DRG, then the payer will use the codes to identify the correct DRG code and reimburse the hospital based on that rate, not based on how much is charged. However, some insurance contracts may have different reimbursement methods, and may pay the hospital, for example, a percentage of the charges billed or a per diem rate rather than using the DRG. It all depends on what that hospital has negotiated with that particular insurance company.

The charges and coding will not be affected in any way by whether the patient is self pay or insured. However, since self pay patients do not have an insurance plan that has a negotiated rate in place for the services they've received, they are just responsible for the bill itself.

Looking at the itemized bill you've attached, it looks to me a bit high but not inappropriately so, and it's not too different from what other facilities I've worked with would charge. It appears that they have given the patient a 25% discount off of the total billed charges, which may be that facility's policy for self pay patients to bring the charges more in line with what other insurance contracts would pay for a similar service. But again, the diagnosis or PCS coding would not change any of what was charged though.

I do have another question for you. This patient was inpatient and then it was determined surgery was needed. I understand the facility charges for resources but am confused about what the PCS coding charges are for, if they are not the same thing? If I am understanding this correctly, the PCS coding is only for determining what contracted rates (for insured patients) or DRG determinations? Could I use the PCS code to request an estimate even in self pay?

 

[thomas7331]

I do have another question for you. This patient was inpatient and then it was determined surgery was needed. I understand the facility charges for resources but am confused about what the PCS coding charges are for, if they are not the same thing? If I am understanding this correctly, the PCS coding is only for determining what contracted rates (for insured patients) or DRG determinations? Could I use the PCS code to request an estimate even in self pay?

There are no 'PCS coding charges'. The PCS are just codes that identify on the claim form what procedures were performed during an inpatient stay. They have nothing to do with charges. The presence of a PCS code might change the DRG (which in turn might change the reimbursement), but it wouldn't change the amount charged for the inpatient stay. Hospitals don't base their charges on PCS codes, and I'm pretty sure they wouldn't be able to give you any kind of estimate for a surgery with that information.