Wiki Same Day Admit/Discharge < 8 hours

[RaeToll]

I have an inpatient claim with TOB 0111, denied requesting a corrected claim with a code explaining the same date discharge. The patient was admitted inpatient status at 14:50 and discharged at 17:35.
Per CMS Manual Pub 100-04 Medicare Claims Processing, CPT codes 99234-99236 require a minimum of 8 hours inpatient stay. The manual directs me to use CPT codes 99221-99223 for same day discharge for less than 8 hours, however, when I ran these CPT codes through Revenue Cycle Pro, it indicated the CPT codes could only be used for TOB 013 (Hospital Outpatient) or 085 (Critical Access Hospital).

Can anyone direct me to what is the correct procedure for a same day discharge for less than 8 hours with a TOB 111?

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1465CP.pdf

 

[thomas7331]

Not sure I understand your situation here. The guidance on the CPT coding is for the professional claim only and there isn't a TOB code on the CMS-1500 claim. TOB is for the facility claim only which won't have any of these CPT codes on it, so there shouldn't be any incompatibility issues here. The physician's codes would follow the CMS guidance for correct assignment of the code for a stay of less than 8 hours. If the facility claim is denying for the incorrect TOB code for a short stay, then that's an issue that the hospital will need to address with the payer - there's no CPT coding involved on the facility claim, and it's not clear to me from the denial you describe what resolution the payer is looking for from you. Are they perhaps looking for a UB condition code or something like that?

 

[RaeToll]

Not sure I understand your situation here. The guidance on the CPT coding is for the professional claim only and there isn't a TOB code on the CMS-1500 claim. TOB is for the facility claim only which won't have any of these CPT codes on it, so there shouldn't be any incompatibility issues here. The physician's codes would follow the CMS guidance for correct assignment of the code for a stay of less than 8 hours. If the facility claim is denying for the incorrect TOB code for a short stay, then that's an issue that the hospital will need to address with the payer - there's no CPT coding involved on the facility claim, and it's not clear to me from the denial you describe what resolution the payer is looking for from you. Are they perhaps looking for a UB condition code or something like that?

The claim is billed on a UB04. This is what the rep in our office provided me, "Claim was denied due to the admit and discharge dates being the same. Payer has stated that we need a corrected claim with a code explaining the same date discharge. We are requesting coding review".

I initially assumed a condition code was required, however, when I searched CMS, the CPT code range 99234-99236 is what was referenced. I've attached a copy of the charges for reference. There is no condition code billed on the UB04. I truly appreciate your help.

 

[thomas7331]

The claim is billed on a UB04. This is what the rep in our office provided me, "Claim was denied due to the admit and discharge dates being the same. Payer has stated that we need a corrected claim with a code explaining the same date discharge. We are requesting coding review".

I initially assumed a condition code was required, however, when I searched CMS, the CPT code range 99234-99236 is what was referenced. I've attached a copy of the charges for reference. There is no condition code billed on the UB04. I truly appreciate your help.

I would send it back to the rep and request that they contact the payer for clarification as to what kind of a 'code' they are looking for. The CMS policy for CPT codes 99234-99236 is not relevant to facility claims.