Wiki Denials

[Gemini18]

Hello -

I audit for a Hospitalist Group. I am working on two reports that were denied by BC/BS.

Case #1:
The physician saw the patient and admitted the patient from the ER at 11:25pm on 9/1/2009, the hospital has the patient admitted on 9/2/2009. What do I do?

Case #2:
Patient comes in to ER on 8/8/2009, seen by the physician, admitted to ICU and released on 8/11/2009. Hospital coded it as an OBS. It was denied, the hospital appealed it and it was denied again: BC/BS's reason was the appeal was past 90 days. What do I do here?

 

[mitchellde]

on #1 check the admit time per the hospital record and then see if the physican recorded the time on his admit note, if they do not agree then you may need to speak with the hospital about changing the admit date.
#2 You need to find out why the hospital billed as an obs. They cannot do this without an order from the physician to admit to obs. There for if you have the order that states admit to ICU and there is no change in that status from the physician then you should be reimbursed on the physician side but you do have the documentation to appeal with. As far as the hosptial goes if they billed as obs and were denied and are now out of the 90 time frame they are done.

 

[Gemini18]

Thanks Debra