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Observation to Inpatient

  1. #1
    Default Observation to Inpatient
    Medical Coding Books
    Okay ... here's my cookie cutter scenario ...

    Day 1 - Admitted to Observation
    Day 2 - Still in Observation
    Day 3 - Status Changed to Inpatient
    (Do you bill for Inpatient Admission here?)
    Day 4 - Subsequent Care
    Day 5 - Inpatient Discharge

    I'm thinking if the status changed to inpatient, you only bill the inpatient stay ... I can't seem to find documentation on this ... it's been a rough day!

    Thoughts??

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default You can do it either way
    AR,
    If your hospital actually "changes" the status of the entire visit to inpatient, then you might be able to just bill the inpatient admission code for day 1 and subsequent visits up till discharge day. (That's what we generally do.)

    However, I have been to many seminars where this scenario has been described and the answer was to code:
    Day 1 99218-20 Initial Observation
    Day 2 99211-15 Outpatient established visit
    Day 3 99221-23 Initial Hospital visit
    Day 4 99231-33 Subsequent hospital visit
    Day 5 99238-39 Hospital discharge management

    Obviously this second approach requires TWO H&P/admission documents - one for observation and one for the initial hospital visit. (That may be why we opt to use option 1.)

    F Tessa Bartels, CPC, CPC-E/M

  3. #3
    Default
    Thank you!

    Now my question is ...... is we code for both the observation days and then the inpatient admission ...... will Medicare reimburse for both? What is their standpoint on this?

  4. #4
    Default
    Okay, I did my homework

    Here's my findings...I wanted to share with everyone.

    Observation Coding

    If admission to observation is 8 hours or less on same calendar day, report 99218 – 99220
    No observation discharge is reported.

    If admitted and discharged from observation on different calendar days, report 99218 – 99220 and observation discharge, 99217

    If admitted to observation for a minimum of 8 hours, and discharged less than 24 hours, report same day admit/discharge, 99234 – 99236

    If admitted to observation and patient stays in observation for more than 2 calendar days, report 99218 – 99220 and 99211 – 99215 for days subsequent to observation admission, also report observation discharge, 99217

    If admitted to observation and then inpatient on same day, report only inpatient admission, 99221 – 99223. Do not report initial observation or observation discharge.

    If admitted as inpatient from observation subsequent to the date of admission to observation, report 99221 – 99223 for the date of inpatient admission.

    Example: Day 1 Admitted to Observation (99218 – 99220)
    Day 2 Subsequent Observation (99211 – 99215)
    Day 3 Inpatient Admission (99221 – 99223)
    Day 4 Subsequent Hospital Care (99231 – 99233)
    Day 5 Discharge Planning (99238 – 99239)

  5. #5
    Default
    AR,
    Thank you for posting this question. I run into this situation all the time and it's great to get come expert advice.
    FTessa--thanks for your input and help
    Carrie, BS, CPC

  6. #6
    Default New Question(s)
    Here's a question the docs are asking now :

    If they are to only bill the inpatient stay subsequent to the admit to observation ....... so in other words, they just aren't going to bill for the observation ....... is this okay? Is deliberating not billing for something ok? I know it sounds like an awkward question but normally on an "outpatient basis" the patient is responsible for more money and on an "inpatient basis" the insurance has to pay more out, as well all know - so would this fall under the False Claims Act somehow?

    Anyone ... ??

    Question #2:

    If they do choose to bill for both the observation and inpatient stay .... the doctors want to know why they would have to re-dictate an inpatient H&P .... I know they have the code requirements to uphold .... but the way they are relaying it to me is "Well, we admit them to observation...they stay for 2 days... we do labs and find out something is elevated, so we have to admit them ... why would we have to redictate the whole H&P when nothing else has changed except for the elevation in labs?"

    I see their point, and I know my point .... Anyone??

    THANKS!
    Last edited by ARCPC9491; 10-10-2008 at 10:04 AM. Reason: correction

  7. #7
    Location
    Milwaukee WI
    Posts
    4,466
    Default Redictating the H&P
    If they want to bill for the Initial Hospital Visit, then they need to have documentation of that service done on that date of service. The only way to do this is to dictate another H&P.

    As to your first question ... well some might argue that you are overcharging by charging for TWO admissions for ONE hospital stay. Bear in mind that we bill each date of service, it's just that we charge the Initial Hospital Visit on day 1, and subsequent hospital visits on each day following until Discharge date. So with your original example we would bill:
    Day 1 - Initial Hospital Visit (99221-23)
    Day 2 thru 4 - Subsequent hospital visit (99231-33
    Day 5 - Discharge (99238-39)

    F Tessa Bartels, CPC, CPC-E/M

  8. #8
    Default
    "I know it sounds like an awkward question but normally on an "outpatient basis" the patient is responsible for more money and on an "inpatient basis" the insurance has to pay more out, as well all know - so would this fall under the False Claims Act somehow?"


    I guess it would depend on the insurance thought as to it costing the patient more for outpatient then inpatient. For example with Medicare when it comes to the dr billing the observation days and inpatient days the patient is is responsible for the 20% for both the inpatient and observation days.
    Herbie W Lorona Jr., CPC, CPC-H
    hlorona@up2parmedicalclinic.com

  9. #9
    Default obs to inpt
    My question is:
    If you charge the patient as an inpatient from day 1 when they were actually admitted as observation, shouldn't your charges match the hospitals? When they have them in as outpatient for 2 days, that's what will be charged for room charges etc. (correct?) then you charge inpatient charges, if this visit is audited would this be a concern?

  10. #10
    Default
    Quote Originally Posted by Anna Weaver View Post
    My question is:
    If you charge the patient as an inpatient from day 1 when they were actually admitted as observation, shouldn't your charges match the hospitals? When they have them in as outpatient for 2 days, that's what will be charged for room charges etc. (correct?) then you charge inpatient charges, if this visit is audited would this be a concern?
    Anna,
    We would charge inpatient the day their status changed from observation to inpatient, not from day 1 when they were observation. So our charges would match the hospitals.

    The question is... when their status does change to inpatient, do we ONLY bill the inpatient stay OR bill for the days they were in observation as well.

    and ... if we only bill the inpatient stay, would we get in trouble for not reporting the observation?

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