Wiki Hospital Outpatient longer than 72 hours

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erine

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This is regarding hospital billing for a neurology group. We have had several claims where the patient was in the hospital for over 72 hours (sometimes a week) and they are listed as outpatient or observation for the entire stay. The hospital is unable to get the auth to make them an inpatient.

We bill using outpatient codes for the visits. We can not use the Observation codes since we are not the attending/admitting doctor. Usually the patients end up with copays for each day and sometimes denials for no referral if they needed one. One claim was denied and the insurance is saying the hospital billed ER codes for the 3 days the patient was there.

Is coding with out patient codes the proper way to bill for these? Can we use the ER codes as well?

Also a general question. How is this possible that patients can be in the hospital for a week as an out patient? I thought there was a 72 hour limit.

Thank you so much. After 8 years of billing and coding I still get overwhelmed by E/M coding.
 
Once the physician writes the order to admit to observation, any bed in the facilty becomes the observation bed. It will not matter if they do not leave the ER, it is at that point observation and use POS 22 with regular E&M codes. The patient will remain in observation status until discharged to home or to inpatient. The conversion to inpatient comes from the admitting provider. The hospital staff cannot make the patient inpatient or observation, it must be a written order from the admitting provider. If the stay goes beyond ordinary reasonable observation time, it is up to the favility UR person to contact the admitting physician to obtain the order to admit the patient or discharge. It sounds like there is a breakdown in communication if you have patients on observation for more than 72 hours.
 
Most of the time we have to write off the charges because the hospital doesn't even get paid. We call the hospital billing department after getting our denials and the hospital states they were unable to make them inpatient and they didn't get paid due to the patients benefit plan so they wrote their claims off.

Yesterday I called the hospital to verify a patient was in fact an outpatient for 6 days straight and they said yes. So since we have seen them in the past in our office now we bill office out patient codes for those 6 days in the hospital and hope we get paid or that the patient doesn't ened up with copays for each day or that they didn't need a referral.

The hospital says the insurance companies are making it more difficult to get the ok to make the patients inpatients. Its very frustrating.

Also sometimes they get the ok on the 3rd day so the first two days we saw the patient we don't get paid and neither do they.
 
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