Wiki OR billing

[mojisola]

Can someone please enlighten me about how OR services should be billed for inpatient services.
I am currently conducting inpatient facility audit and I see surgery time listed on the surgical notes as the exact start and end time for anesthesia. ie
if anesthesia bills 3 units the surgery time bills 45 minutes. Is this correct?

Thanks

 

[thomas7331]

I don't think there is any rule that dictates how facilities must charge for OR services. The facilities where I've worked have based this on the amount of time that the patient is in the OR (which could be longer than anesthesia time, since anesthesia might start some time after the patient is actually brought into the procedure room). These charges are entered by the OR staff who follow guidelines given by the facility as to how they should determine the number of minutes or units that should be charged - this is not done by coding staff. If you're charged with auditing the accuracy of this, you would need to find out what those guidelines are in order to be able to determine if they were followed correctly or not.

I'm not sure that it really matters in the end though, especially in the case of an inpatient claim, because facility reimbursement is based on DRG or outpatient case rates based on patient acuity and procedures performed and not on the amount of the charge. Or by chance are you auditing for overpayment recovery on a percentage of charge contract? If that's the case, you'd need to look at the facility's contract with the payer to know if the payer has any specific contractual requirements that stipulate how these charges should be calculated. Without that, there really is no standing to make a claim that the facility has billed incorrectly by using one particular method or another to determine how they calculate their charges.

 

[mojisola]

Thanks so much for your help. Yes I am auditing based on fee for services and I will be looking at the payer contract.
In addition is there any case when NCCI edits apply to inpatient services especially lab.

 

[thomas7331]

Thanks so much for your help. Yes I am auditing based on fee for services and I will be looking at the payer contract.
In addition is there any case when NCCI edits apply to inpatient services especially lab.

NCCI edits would not apply because no CPT/HCPCS codes are submitted on inpatient claims, so there are no codes to which an edit can apply.

 

[mojisola]

This is a fee based audit and labs are typically billed with CPT/HCPCS codes for inpatient claims.

 

[thomas7331]

This is a fee based audit and labs are typically billed with CPT/HCPCS codes for inpatient claims.

Not sure I understand what you mean. CPT/HCPCS codes are not part of the HIPAA code set for inpatient UB-04 claim submissions. Whatever audit you're doing, you'll go have to go with the language of the contracts or the guidelines that your auditing organization has given you - you're outside of standard coding rules here.

 

[mojisola]

Thanks!