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stmsmithstmsmith
in BILLING AND CLAIMS
Hi all, I have a question. We had a patient that came through the ED December 23 @ 12:49 through the ED, admitted to IP @ 19:17.  They were changed to Obs at 20:02. Then had an admit order for 12/24 at 10:16 and d/c'd on 12/26 @ 4p.  When CM was trying to place the patient to the NH, they told the NH she had been there 3 days when she was only 2 days since a few hours was for Obs.  The account went to the CM Committee and they agreed with IP status.  So now we are trying to determine how we don't have to payback the $23k? Any thoughts?

Comments

  • ronaldhirschronaldhirsch
    Was the change to Obs done compliantly at the time with review by the UR Committee member and written notification to the patient? If not, then the change is not valid and the patient remained an inpatient from the first order. So you will need to resubmit the claim and then tell the SNF to do the same.

    If it was done compliantly, then there was no 3 day stay. But actually you owe nothing; it is the responsibility of the SNF to verify the qualification for part A and if there is no qualifying stay, it is a patient obligation to pay (yep, even without an ABN). Now you can pay to be nice but you are not required to do it. 
  • stmsmithstmsmith
    Thanks Dr Hirsch. The UR committee met the next morning after the patient was placed in Obs status and he agreed that the patient should have stayed in IP status.
  • stmsmithstmsmith
    Question, so would I just remove the Obs charge and make a 3 day IP from the 1st order?
  • ronaldhirschronaldhirsch
    Yep- if the CC44 process was not completed properly, the order to change the status is invalid. You ignore it. Imagine a doctor ordering an MRI but the patient dies before the MRI is done; are you going to bill for that MRI? Of course not. So the admission began with the first order and continued until discharge. 
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