Wiki Outpatient vs Inpatient

[kristin2699]

I have a claim from 2016 that was billed out by our old billing company and now the insurance is requesting the whole payment back. The claim CPT code is 27486 they state the claim was billed without an admission stay. He was admitted on 2/24/2016 and discharged on 2/25/2016. Does it really matter if it was billed as an inpatient or outpatient it would still be paid at the same rate right? Also isn't it too late to rebill the claim after that many years?

 

[Orthocoderpgu]

I think what you may be dealing with is an insurance policy issue. And yes, it makes a difference billing inpatient vs outpatient. It used to be that joint replacements were always an "Inpatient" procedure. Now it can be done as an "Outpatient" procedure. The billing company may have billed with the wrong POS code which somehow was still paid. Also keep in mind that the facility bill comes into play as well. If the physicians bill and facility bill don't match the POS code, one or both charges may be denied. Any fixes to this probably depend on the contract that you have with the insurance.

 

[sls314]

Was the stay inpatient, or was the patient kept for 24-hour observation? Staying overnight doesn't necessarily mean that the patient was admitted to inpatient status.

In 2016, CPT 27486 was classified as an inpatient-only procedure by CMS. (You can see this on the OPPS Addendum B effective for the DOS - 27486 is listed with a Status Indicator of C, which means inpatient-only.)

It sounds like the insurer is trying to use that information and say that your claim isn't payable because of that.

Can they do that? Well...much of that depends on your contract with the insurer. It's hard for us to say here without knowing what your contract language says. You (or the contracts person for your practice) need to pull out a copy of the contract and review the relevant passages.

See if there are any time limits in the contract on how long they have to initiate recoupment. See if the contract references anything about following CMS rules or policies. If the insurer is doing something not permitted in the contract, then I'd appeal the recoupment making specific references to the provisions in the contract.

If you have a billing contact at the facility, you may also want to check to confirm whether the patient was classified as inpatient or observation. Just so you have that information for reference in any appeal you send as well.

Good luck!