out patient surgery/admitted

jpenland1

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good afternoon all! i think i know the answer to my own question, but i am always second guessing, so in that case i need a few opinions please.

We had a patient that had a shoulder scope, and because of her age was admitted over night. Clearly in the Op note, it says this. She was discharged the next day, but because it was just over night, should it be billed out Out patient? I am saying no, it should be billed as inpatient. any thoughts? Thanks in advance!

Jen P:rolleyes:
 

mbort

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23 hours or less is still considered outpatient. It will be important to find out what her true "admit" time was as well as her discharge time.
 
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Is this automatic?

Mary,
I'm not sure that it is automatic that if the stay was less than 24 hours it is considered outpatient (observation).

I've seen patient's admitted to inpatient status in the evening and wind up going home the next day. We code them as inpatient admits and discharges.
(I'm dealing in pediatrics, so we're not talking about Medicare.)

Also ... time should really be noted using the 24-hour clock, so there's no question of a.m. vs p.m. It seems most of our hospital charts use the 24-hours clock.

F Tessa Bartels, CPC, CPC-E/M
 
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kmihevc

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I would contact the hosptials HIM department and verify the patients status. It is correct that generally patients who are less than 24 hours are admitted but it is under the umbrella of observation and therefore should be coded as an outpatient status. On ocassion, a patient can be a full inpatient admit and then be released before 24 hours. Your best source for the patients status is to check with the facility.
KMihevc, RHIT, CPC
 
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