Wiki 1 tax ID, two NPI's. 1 ER visit, 1 inpatient stay

[juanibc]

Hello all,

I am stumped. A patient came in to the ER at one Hospital. Then left. He came back to another Hospital and was admitted. Both Hospitals share the same Tax ID, but have different NPI's. Is the ER visit from the first hospital still inclusive to the Second Hospital admission? Asking because they are separate facilities, different NPI's, and Insurance is asking for a refund. I cannot find any regulations that are specific enough. I only see that ER's are inclusive to Inpatient unless for a different DX code... but not about different facilities... My guess is that it would still be inclusive since I cannot find verbiage to fight the refund request... Thoughts?

 

[thomas7331]

Since the patient left the facility, this would be considered a separate encounter for coding purposes. But whether or not it is inclusive to the inpatient stay will really depend on the payer’s reimbursement rules. Some payers may follow Medicare’s rule and include all related outpatient services under the same tax ID in the 3 days prior to admission as part of the DRG payment. You’d need to review your facility’s contracts and the payer policies to know for sure.