ER to Observation


Washington, NC
Best answers
Can anyone tell me if they have found any guidelines regarding ER to Observation admission time ? Do we use admission dispostion time when it was ordered ? Or do we use the time the pt was actually admitted to oberservation? :)
Observation Time

Guidance regarding Outpatient Observation Services can be found in the Medicare Claims Processing Manual, Chapter 4, Section 290 ( . Per the manual:

“Observation time begins at the clock time documented in the patient's medical record, which coincides with the time that observation care is initiated in accordance with a physician's order. Hospitals should round to the nearest hour. For example, a patient who began receiving observation services at 3:03 p.m. according to the nurses' notes and was discharged to home at 9:45 p.m. when observation care and other outpatient services were completed, should have a “7” placed in the units field of the reported observation HCPCS code.”

I suggest you read all of Section 290 including the subsections as they are very informative. You may also find it helpful to read the Medicare Claims Processing Manual, Chapter 1, Section 50.3.2 ( regarding Condition code 44. I hope this information helps you on your journey.
As long as the topic is observation billing, I have a quesiton, we have a few claims that we are getting denied because we are billing them as inpatient. (Physician billing) We have an admit on the 15th, daily on the 16th and discharge on the 17th. 99222, 99232, and 99238 with location code 21. We have called Humana because they have denied the claims stating the hospital billed the services as Observation. I called the hospital and they told me they can bill services for up to 72 hours as observation and they don't have to change it unless the doctor tells them to. Since I do not do hospital billing I do not understand the reasoning behind this. Can anyone tell me if this is correct and why would they be considered observation if they were in the hopsital for 3 days?