Wiki Observation and ER

[kendalb]

How can observations be billed to Medicare to include the ER visit for the previous day? I have added the occurrence span code 72 with the date of the ER visit and Medicare is still denying the claim for dates of service outside the service date range. An example is below.

The patient presented in the ER on 7/15/16 at 10pm. The patient was changed to observation status on 7/16/16 at 2am. The dates of service on the claim only reflect 7/16/16. The ER charges still have to be billed on the claim.

The occurrence span code 72 is supposed to notify the provider that there are outpatient dates of service prior to the observations dates.

Any help will be greatly appreciated.

 

[danskangel313]

It's not necessarily the date/time factor here. The pt was in the ER at the time in which the decision was made to move him/her to observation. Admission to observation occurred during an encounter in the ER. Any care provided to the pt in the ER happened up until the admit, so essentially the pt was admitted to observation immediately from the ER (same date and time). Once the decision to admit occurred, assuming it wasn't a same day admit/discharge, the provider who made that decision bills the initial observation care. Any care leading up to the admit is considered inclusive to the admit, BUT the care provided while the pt was in the ER can be counted when leveling the admit charge.

Basically, there should be no charges for the ER as they are considered inclusive of the admission. So if the ER physician is the one who made the decision to admit, then he/she would bill for the admit, NOT the ER charges, but he/she can include the work provided prior to the admit when determining the level of the admit code. If it wasn't the ER physician who did the admit, then the provider who did the admit counts in the work done in the ER, but there are still no charges than can come from the ER visit alone.

It would be different had the patient left and came back. If there was a break in the encounter with the ER and the admit, then the ER could bill separately, but that's not the case here. The time factor only comes into play when the second and subsequent date comes, then a sub care code would be used. Any services provided on the date of the admit (including the encounter leading up to the admit) are all inclusive to the admit.

The reason for the denial about the date span is because the admit occurred during another encounter and the time in the ER has now been grouped into the admit date. Bundled if you will. There should be no charges for 7/15. The charges begin 7/16, BUT the amount of work done between those few hours prior and after midnight aren't "thrown out" because the work gets counted in and can level the admit higher, which means a higher reimbursement.