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Can you bill for ER visit if Admited

  1. #1
    Question Can you bill for ER visit if Admited
    Medical Coding Books
    I don't usually bill for hospital claims, but need to know how you would bill for Emergency Room charges & then Inpatient charges, if the patient comes into the emergency room for breathing problems (428.0) and then is admitted for (428.0).
    Would you bill for ER charges & then the Hospital charges? OR since the patient was admitted their would be no ER charges?

  2. #2
    Location
    Concord, NC or Rochester, NY
    Posts
    154
    Default
    If the ER doctor admitted then the ER visit would be rolled into the admit. However, if the ER doctor did the ER part and a hospitalist admitted, then there would be two charges - the ER doctor for the ER and the hospitalist for the admit

  3. #3
    Location
    Columbia, MO
    Posts
    12,531
    Default
    If you are billing for the facility I say yes you bill for the er visit as an outpatient claim and the inpatient visit as an inpatient claim. The Er visit is paid based on OPPS and the inpatient based on DRGs. Since the implementation of OPPS I have run into only a few situations where the payer rolled the ER visit into the admit. Let the payer decide.

    Debra A. Mitchell, MSPH, CPC-H

  4. Default FacilityCs. Physician
    On the facility side the ED visit is usually rolled into the hospital DRG. The exception would be only if the ED visit were clearly unrelated to the hospital admit. And this would have to be backed up with documentation. CMS clarified the 72 hour rule in June of 2010 and became much more strict about the ED facility visit being rolled into the hospital admission.
    On the physician side, both the ED physician service and hospital visits can be billed.

    Jim

  5. #5
    Location
    Seacoast- Dover New Hampshire
    Posts
    609
    Default
    We are a CAH and the POS for ER is 22 but the IP is 21. We have to seperate claims for 1500 and UB's.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  6. Default Here's The Rule
    "Updates to the “3-Day Payment Window” or “72-Hour Rule”
    Federal Register pages 25,960-25,961
    Background: The Preservation of Access to Care Act of 2010 modified the Medicare payment policy regarding
    how hospitals may bill for outpatient non-diagnostic services related to an inpatient admission (other than
    ambulance and maintenance renal dialysis services) provided on the day of admission or during the 3-days (72
    hours) prior to the admission. This policy is generally known as the ‘‘3-day payment window'' or “72-hour
    rule.”
    Under the modifications made to the 72-hour rule, all outpatient non-diagnostic services provided by the
    hospital on the date of the inpatient admission or during the 3-days immediately preceding the date of the
    inpatient admission are deemed related to the admission and must be billed with the inpatient stay unless the
    hospital attests to specific non-diagnostic services as being unrelated to the hospital claim. Prior to the
    legislative change, hospitals were allowed to bill or, in some cases, re-bill Medicare Part B for these nondiagnostic"

    It could be that Rural or underserved haspitals are waived from these requirements. But I was involved with a consulting company that took a liberal view of the 72 hour rule. The CMS clarification was basically a reaction to hospitals that were billing ED visits separately from the DRG. This was one of those gray areas where even a one digit difference between the hospital diagnosis and ED diagnosis would be considered unrelated. Now the ED for an ankle sprain then they are admitted for an MI two days later would be OK to bill separately if other requirments are met.
    But again maybe there is a waiver for CAHs.[

  7. #7
    Question ER visit with surgery
    Let me see if I have this right...

    Auto accident with internal injuries requires surgery.

    ER doctor bills 99284 and transfers patient to surgeon for evaluation/surgery.
    Surgeon does the surgery bills for surgery.
    Hospital bills 99284 and for the surgery.

    Is this correct? What, if any, modifiers would need to be used?


  8. #8
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Quote Originally Posted by tboback View Post
    Let me see if I have this right...

    Auto accident with internal injuries requires surgery.

    ER doctor bills 99284 and transfers patient to surgeon for evaluation/surgery.
    Surgeon does the surgery bills for surgery.
    Hospital bills 99284 and for the surgery.

    Is this correct? What, if any, modifiers would need to be used?

    On the face of things yes but the hospital E&M does not have to match the physician level as it is based on different criteria, so the hospital level could be anything between 99281 and 99285 but yes to answer your question. The hospital will use the 25 modifier on the E&M level.

    Debra A. Mitchell, MSPH, CPC-H

  9. Default Not with Medicare
    This might be the case with an auto accident. But with Medicare or payers that follow Medicare guidelines, if the patient is admitted within 72 hours for a related reason, there is no billing 99284 for the hospital. That is wrapped into the hospital DRG.

  10. #10
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Quote Originally Posted by jimbo1231 View Post
    This might be the case with an auto accident. But with Medicare or payers that follow Medicare guidelines, if the patient is admitted within 72 hours for a related reason, there is no billing 99284 for the hospital. That is wrapped into the hospital DRG.
    The poster did not state the patient was admitted so I assumed outpatient surgery with the ER visit.

    Debra A. Mitchell, MSPH, CPC-H

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