Inpatient on day of discharge
I would like to pick everyone's brains... Our organization contracts with a vendor who has instructed our physicians to convert all patients to inpatient status after two midnights, regardless of medical necessity. This has resulted in physicians writing inpatient orders on the day of discharge, sometimes even after the discharge order has been written. If an inpatient claim needs an inpatient room charge to go out the door and you don't charge rooms on the day of discharge, how do you handle this? Because it's paid on the DRG, do you allow the room charge on the discharge date? Not a problem on the UB but could be problematic if/when the payer requests an itemized bill. Do you leave the Observation hours on the claim? This issue has become a hot topic between our vendor, Case Management, Revenue Integrity, and Compliance. Any words of wisdom will be most appreciated!
Comments
So, first off, I do not agree with the vendor's suggestion for a few reasons. I have one below, but there's more out there.
https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/downloads/ip-certification-and-order-01-30-14.pdf
Timing: The order must be furnished at or before the time of the inpatient admission. The order can be written in advance of the formal admission (e.g., for a pre‐scheduled surgery), but the inpatient admission does not occur until formal admission by the hospital. Conversely, in the unusual case in which a patient is formally admitted as an inpatient prior to an order to admit and there is no documented verbal order, the inpatient stay should not be considered to commence until the inpatient admission order is documented. Medicare does not permit retroactive orders . Authentication of the order is required prior to discharge and may be performed and documented as part of the physician certification.
However, there are legitimate times where the patient may be discharged on the same day, so here's the guidance for that.
https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c03.pdf
K - Inpatient Acute Care Hospital Admission Followed By a Death or Discharge Prior To Room Assignment A patient of an acute care hospital is considered an inpatient upon issuance of written doctor’s orders to that effect. If a patient either dies or is discharged prior to being assigned and/or occupying a room, a hospital may enter an appropriate room and board charge on the claim. If a patient leaves of their own volition prior to being assigned and/or occupying a room, a hospital may enter an appropriate room and board charge on the claim as well as a patient status code 07 which indicates they left against medical advice. A hospital is not required to enter a room and board charge, but failure to do so may have a minimal impact on future DRG weight calculations.