Cardiology Coding Alert

Question: We occasionally receive denials for heart catheterizations, stating that the place of service is incorrect. After research, we have found that the hospital reported one place of service (inpatient) while we reported another (outpatient). What can we do to avoid problems like this?

New Jersey Subscriber

Answer: This is a common problem. The hospital's billing for the technical portion of the procedure, either as outpatient or inpatient, and the physician's reporting sometimes don't agree. The problem most practices discover is miscommunication.

Keep in mind that the doctor determines whether the patient is an outpatient or inpatient. That determination is going to be (or should be) based on whether the physician thinks that the patient is going to require 24 hours of care after the procedure or less than 24 hours after the procedure. The number of hours of care the patient requires in that skilled setting doesn't really matter. What matters is the physician's determination before the procedure is done.

One way to cut down on the frequency of these denials is to establish a protocol and make sure that everyone (the hospital and your practice) understands it. Specify that every time your cardiologist sends a patient to the hospital for catheterization, he or she will be considered an outpatient unless otherwise specified with specific verbiage such as "admit to inpatient status."

Some physicians have the habit of using the word "admit" freely. In some instances, they might intend "admit to inpatient status," whereas in another, they might intend "admit to observation status." By clarifying this distinction, you should see denials of this nature decline.