Wiki Inpatient Surgery Help

[ccoleman822]

Hey,
I'm not sure if this is the right forum, but I figured I'd post this question here. My spine surgeon is doing a C3-C6 decompression and fusion, the patient will need an ICU stay after surgery per Dr. However, the hospital is stating this procedure can only be done Outpatient, even though we know that is incorrect. This is causing trouble for us because the ICU is getting the procedure and denying the stay because it is stating Outpatient. He is giving the codes to the precert department at the hospital, which is protocol for our area, and they are seeing the first code on the list which is 63045 and they stop and tell the provider it is going to be an Outpatient surgery because these are Outpatient CPT codes. I've never heard of this and was wondering is this common hospital practice? Or does my hospital just not know what they are doing?

The codes being performed are: 63045, 63048x3, 22842, 22600, 22614x2, 61783, 20660, 20930, 20936.

Like I said hospital is telling us that this surgery is an Outpatient surgery not Inpatient because the codes are designated as Outpatient, which I've never heard of codes being designated OP vs IP.

any help on this matter will be greatly appreciated.

 

[thomas7331]

I agree with your take on this - there is such a thing as procedures which are 'inpatient only', but I've never heard of procedures designated as outpatient only. It sounds to me like there is some kind of communication breakdown here between your physician and the hospital and the insurance company. Admission to inpatient status should be based on the expected needs of the patient, not on what particular procedure is being performed. It's possible that the hospital or insurance may need some additional information to justify the authorization for inpatient admission, such as co-morbidities or conditions that make the surgery higher risk, but I'm just guessing here. I think you just need to get the right person on the phone and get this worked out. If your physician expects that an inpatient admission is medically necessary, then there needs to be a dialogue with the person on the other end who is giving you this information to find out what criteria they are using to arrive at this decision.

 

[ccoleman822]

I agree with your take on this - there is such a thing as procedures which are 'inpatient only', but I've never heard of procedures designated as outpatient only. It sounds to me like there is some kind of communication breakdown here between your physician and the hospital and the insurance company. Admission to inpatient status should be based on the expected needs of the patient, not on what particular procedure is being performed. It's possible that the hospital or insurance may need some additional information to justify the authorization for inpatient admission, such as co-morbidities or conditions that make the surgery higher risk, but I'm just guessing here. I think you just need to get the right person on the phone and get this worked out. If your physician expects that an inpatient admission is medically necessary, then there needs to be a dialogue with the person on the other end who is giving you this information to find out what criteria they are using to arrive at this decision.

Thank you for your reply,
I will say the provider gives them enough information to justify the necessity. We have just been having a rough go because the provider is a new spine Surgeon and we think the hospital is just not used to this and they are just giving us incorrect information because they don't understand/know what to do in these situations. Because one of the principal diagnosis is cervical disc disorder with myelopothy. To the hospital it means nothing and they are so caught up in that 63045 being an designated outpatient code, that is their answer on each case. I just think they don't know what they are doing.

 

[thomas7331]

Thank you for your reply,
I will say the provider gives them enough information to justify the necessity. We have just been having a rough go because the provider is a new spine Surgeon and we think the hospital is just not used to this and they are just giving us incorrect information because they don't understand/know what to do in these situations. Because one of the principal diagnosis is cervical disc disorder with myelopothy. To the hospital it means nothing and they are so caught up in that 63045 being an designated outpatient code, that is their answer on each case. I just think they don't know what they are doing.

I would just escalate it up the chain of command - see if you can speak to a supervisor. It's not up to an administrative person at a hospital or insurance company to make a final determination as to whether or not a patient needs to be admitted.