Wiki Patient seen in Emergency Dept in POS 23 while inpatient status in HRC program.

[sammartin92472]

We are having issues with Humana Medicare recouping payments made for ED visits (99282-99285) billed in POS 23 for patients who they indicate are in an inpatient status. Many of these patients are inpatient in our own system in a Home Recovery Care program in which patients who were inpatient in the facility are sent home to recover techncially in an inpatient status. When they have a complication or some issue that needs attention, they will come to the emergency room for evaluation and or treatment but are "technically" still inpatient in our facility. I tried billing our ED visits in POS 21 which is the current POS they are in but we have denials that the ED E/Ms are not covered in that POS. Can we just not be reimbursed for any ED visits while the patient is in this status? We also have patients who are inpatient in our behavioral health hospital in POS 51 that get sent to our ED for any medical emergency issues and we face the same problems. I don't know if this is just a situation where we cannot be separately reimbursed in the ED when the patient is in an inpatient status?

 

[Pam Warren]

You can bill only the professional component, not the technical charge and you'd have to use the hospital IP or OP codes for the POS where they are admitted.
All facility charges will be bundled into the IP facility stay, but if medically necessary, the ED doc should be able to bill for their E&M visit, but in the correct POS.

Otherwise, they would need to be discharged from the IP stay in order to go to the ED; and then readmitted later.

 

[sammartin92472]

You can bill only the professional component, not the technical charge and you'd have to use the hospital IP or OP codes for the POS where they are admitted.
All facility charges will be bundled into the IP facility stay, but if medically necessary, the ED doc should be able to bill for their E&M visit, but in the correct POS.

Otherwise, they would need to be discharged from the IP stay in order to go to the ED; and then readmitted later.

I only bill for the professional charges on the CMS 1500, i don't handle any facility billing. The issue with these particular ones is that they are admitted inpatient at our own health system but they are at home recovering as inpatients or they are admitted to our psych hospital which is part of our own health system. I tried billing the ED charge in POS 21 but evidently Humana won't allow an ED charge to be reimbursed in POS 21 so I can't do that. I don't really have the ability to have a patient discharged from an IP stay when they come into the ED so I seem to have my hands tied on this one.