# Can you bill for ER visit if Admited



## lamreed

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?


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## mdoyle53

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


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## mitchellde

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.


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## jimbo1231

*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


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## kbarron

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.


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## jimbo1231

*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.[


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## tboback

*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?


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## mitchellde

tboback said:


> 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.


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## jimbo1231

*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.


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## mitchellde

jimbo1231 said:


> 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.


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