Error in Admit to Observation Order

DebRDebR
in GENERAL

Looking for some help on this one. We have a case where a patient's provider sent the patient to our facility as a Direct Admit to Observation. The patient arrived, had some lab test and hydration services. All notes, provider documentation, lab and ancillary orders have the correct service date. Unfortunately, the order for Admit to Observation has an incorrect date.

I think we should be okay billing for the observation, based on all of the documentation, but our billing department doesn't agree.

I'm sure I have seen guidelines on how to handle errors on orders (when it is clear that the error is a data entry error) that indicates as long as we have clear, supporting documentation, we should be okay.

I would appreciate any guidance.

Comments

  • DebRDebR

    I believe this is what I was thinking of:

    The 2014 Inpatient Prospective Payment System Final Rule, also known as the “two-midnight rule”, reads that “in the extremely rare circumstance the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors are provided with discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record.”

    Can the same logic be applied for Observation orders? I would think it can be inferred that this would apply for any type of admission order.

  • goodjegoodje

    I would say yes, as long as the other documentation supports that the date was an error. Not specifically billing related, but here's a JHACO link that has some info about date errors: https://manual.jointcommission.org/releases/TJC2021A1/DataElem0816.html

  • DebRDebR

    Thanks, goodje!

  • RHirschRHirsch

    My philosophy is that clerical errors can just be corrected. If the verbal order is transcribed incorrectly, just fix it. But if they ordered inpatient admission and later are told that observation was correct status, that has to go thru the process.

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