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Thread: Hospital admission downgraded

  1. #1

    Smile Hospital admission downgraded

    AAPC: Back to School
    Patient is admitted to the the hospital by physician. The patient is then "downgraded" by the hospital as not meeting the admission criteria.

    Do we bill the inpatient visits as outpatient visits because the patient was "downgraded"?

    Thanks for any information you may have on this scenario.

  2. #2
    Join Date
    Apr 2007
    Hartford, CT


    You have to bill based on what the hospital is billing, if they bill inpatient your charges will reflect inpatient; if they bill as observation, outpatient or ER your charges will reflect that. If you try to bill inpatient (99231-99233) code and the hospital has billed outpatient or observation your claims will be denied by the insurance company becaue they will not have a facility bill to match your charges. So to answer your question, yes you will bill outpatient charges.

    Since physician documentation in the hospital tends to be very brief, when this happens in our office I also get the hospital notes to verify the level before I code the charges. Hope this is helpful.

    Doreen, CPC

  3. #3
    Join Date
    Apr 2007
    North Carolina


    50.3 -When an Inpatient Admission May Be Changed to Outpatient Status

    Patients are admitted to the hospital as inpatients only on the recommendation of a physician or licensed practitioner permitted by the State to admit patients to a hospital. For more detail, see the hospital Conditions of Participation (CoP) at 42 C.F.R. §482.12(c). In some instances, a physician may order a beneficiary to be admitted as an inpatient, but upon reviewing the case, the hospital’s utilization review (UR) committee determines that an inpatient level of care does not meet the hospital’s admission criteria.

    50.3.2 - Policy and Billing Instructions for Condition Code 44

    In cases where a hospital utilization review committee determines that an inpatient admission does not meet the hospital’s inpatient criteria, the hospital may change the beneficiary’s status from inpatient to outpatient and submit an outpatient claim (bill type 13x or 85x) for medically necessary Medicare Part B services that were furnished to the beneficiary, provided all of the following conditions are met:

    1. The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;
    2. The hospital has not submitted a claim to Medicare for the inpatient admission;
    3. A physician concurs with the utilization review committee’s decision; and
    4. The physician’s concurrence with the utilization review committee’s decision is documented in the patient’s medical record.
    When the hospital has determined that it may submit an outpatient claim according to the conditions described above, the entire episode of care should be billed as an outpatient episode of care on a 13x bill type and outpatient services that were ordered and furnished should be billed as appropriate.

    There is more to read but I've provided some of the "highlights"...


  4. #4

    Default Hospital Admission Downgraded

    This information helps alot!
    This scenario is our first encounter and we know it will not be the last.

    Thank you so much Doreen and Rebecca!

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