Wiki Er billed with observation charge

[tiffmand]

Please - any guildline advice on providers billing an ER charge with OBV charges.

---- OBV = observation.

We have a discussion in regards to if it matters when a patient is seen less than 24 hours - when they come in by ER. Is this claim reimbursed has an ER, or is the claim consider OBSERVATION since a observation code was bill.

Most carriers that I have worked with guidelines states that as long as an a 760 - observation is billed then the claim is considered observation, not ER. BUT, does time matter?

If a patient status changes to OBV and is in OBV for 3 hours, or 6 hours, less then 24 hours, is this claim considered still an ER bill? Since the OBV hours were not "up to 24 to 48 hours" does this mean the claim is an ER and not a OBV stay?

The patient is moved to OBV, the status changes correct?

Or does it matter on the REV code / Or is this coding/reimbursement dicated by the carrier? Meaning that each carrier is different - there is no global guildelines they have to follow.
760
Treatment/observation room
761
Treatment room
762
Observation room
769
treat/observation room - other

Thank you so very much for your time.
TiffanyM.

 

[mitchellde]

the difference is a physician order, it is not a timed thing. The physician MUST wirte an order to admit to observation for it to be billed by the facility or the physician as an observation. Any bed in the facility can be that observation bed, so an ER patient can be an ER patient for 20 hours or can be an observation patient depending on whether there is an order or not.

 

[tiffmand]

Obv vs er bill

Thank you so much for your reply and I agree with you 100%. The physican's order is what should always be coded.

My question is more towards reimbursement.

The claim has both rev codes 450 - ER and a rev code 760 for OBV. ( At this point the claim is billed with both codes,) - and of course Im sure you know as well, claims are not billed with physicans orders - unless the carrier request them.

Once the claim is processed by the insurance - how should the claim process, is the claim considered as an ER bill or is the claim considered an OBV stay. When a claim is billed with both codes.

During a discussion, I was told that if both codes are on the bill the claim "could be considered an ER bill" and not an OBV bill based on the number of hours the patient was in OBV.

But - I did not like this answer, if the claim is billed with an OBV the claim is an OBV claim, it is no longer an ER visit since the patient status changed. The insurance would reimbused the claim as an OBV claim and not an ER claim - meaning no ER copay will we taken, benefits would be paid as an outpatient visit.

Ok - to bring all back together, if a claim is billed with an 450 and 760 is the claim an observation?

Thank you!

TiffanyM.

 

[mitchellde]

for the hospital claim many payers will pay for both, you need to have both rev codes and both levels of service, so you can charge for both encounters in the facility since APCs took effect.

 

[tiffmand]

Er vs obv

Thank you for your replies.

***all replies are welcome please**. This may be more of an insurance question.

To your reply, yes, the insurance pays for both the ER and the OBV charge, but what I am trying to find out is if he claim is an ER claim or if the claim is OBV claim. - At the insurance level -

Here the difference - an ER bill is usually subject to a flat copay. When a ER - 450 is billed then the patient only pays a copay.

When a OBV charge is billed with and ER visit - there is usually no copay-the claim is now an OBV claim and is subject to ded-co-ins.

What I am trying to find out if there is some rule that states that a claim billed with an OBV and an ER charge that in some cirumstance the claim still would be considered as an ER bill even if there is an OBV charge on the claim.

I was informed that the above was true by a co-worker. But I am trying to verify this. I don't think this is correct.

Thanks
TiffanyM.