inpatient

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I have a patient seen in the office on 04/04 who was direct admitted to our
local hosp the same day for surgery the next day, 04/05. The day he was
seen in the office (04/04) we applied a short leg splint. However, medicare
denied our application/material codes saying he was inpatient. Who is
responsible for this bill?


Kara L. Andrews, R.M.A.
Practice Manager
Gynecology of Venice, P.L.
Orthopaedic Center of Venice, P.L.
241 Nokomis Ave. S., Ste. A-B
Venice, FL 34285
941-485-9941/941-485-3302

Comments

  • The application should still be paid by Medicare. Do you have a 58 modifier on the cast application. Stating that this procedure was a lesser or staged procedure. The POS would be inpt as well, even though your provider saw the patient in your office since the patient was a direct admit.

    From: Kara Mikluscak [mailto:kmikluscak1@gmail.com]
    Sent: Wednesday, June 15, 2016 4:23 PM
    To: Multiple recipients of list PARTB-L
    Subject: [partb-l] inpatient

    I have a patient seen in the office on 04/04 who was direct admitted to our local hosp the same day for surgery the next day, 04/05. The day he was seen in the office (04/04) we applied a short leg splint. However, medicare denied our application/material codes saying he was inpatient. Who is responsible for this bill?


    Kara L. Andrews, R.M.A.
    Practice Manager
    Gynecology of Venice, P.L.
    Orthopaedic Center of Venice, P.L.
    241 Nokomis Ave. S., Ste. A-B
    Venice, FL 34285
    941-485-9941/941-485-3302

  • edited May 2017
    Hello,

    No sorry I don’t agree with that at all.

    Modifier -58 is not appropriate in this situation and neither is billing for POS 21 when the pt was seen in the office.

    I would say you need to appeal and show them that the pt was in your office prior to the admission.

    Erica

  • edited May 2017
    who admitted the patient, if your doc, the office visit should be rolled into inpt admission charges.
    Sharon


  • edited May 2017
    ditto.

    I am curious as to whether the doctor that actually admitted the patient is part of your group and same specialty or not. If so - Medicare is going to assume the "DNA" is the same between the doctors and justify not paying for the office visit for a reason related to the admission.

    Don


    Don Self & Associates, Inc

    305 Senter Ave, Whitehouse, TX 75791
    903 871-1172 fax 480-247-5650
    donself@donself.com web: www.donself.com
    free webinars at www.donself.com

    DISCLAIMER: This email should not pose any visual, auditory or sensory defects in the average reader. If you are now or have been dead or stupid in the past, this email will probably not help you. If you know anyone reading this email who is not from earth - you should immediately seek medical attention. If you have been or plan to be an imbecile in the future, please do not read this disclaimer. These warnings are not valid in the state of Hawaii, Alaska or New Hampshire.

  • We have had the same thing happen in our practice and we ended up adjusting off the charge for the splint application because we appealed multiple times and the cost was already out waying the splint application. I have just educated my providers that if they have a direct admit they cannot perform any services in office and have to wait until patient is admitted so we can bill admit and procedure with the POS of 21.

  • edited May 2017
    My first question would be what kind of splint was applied? Was it a splint that the providers had to shape specific to the patient or was it an off the shelf splint which only required placement not formation. It has always been my understanding if the provider knows they (the same provider) are going to do fracture care then the initial splint application is not separately billed.



  • It was our physician who admitted the patient to the hospital for a
    revision of an ankle ORIF.

    Thank you for all of your suggestions!

    Kara L. Andrews, R.M.A.
    Practice Manager
    Gynecology of Venice, P.L.
    Orthopaedic Center of Venice, P.L.
    241 Nokomis Ave. S., Ste. A-B
    Venice, FL 34285
    941-485-9941/941-485-3302

  • It's not the office visit that I'm speaking of, the procedure that the provider does in the office should be payable.

  • edited May 2017
    Since it was your physician that admitted the patient into the hospital for a related reason to the office visit performed on the same day, you can't bill the office visit. Medicare considers the physicians in a practice of the same specialty to have one DNA - so that if one does something on one day - so did each of the other physicians - so in their mind - it was the same doc who saw the patient in the office and then decided to admit. The admit includes any related E&Ms performed on the same day.

    This means that you need to take the progress note for the office visit into consideration when deciding which level of initial hospital visit to bill.

    Don


    Don Self & Associates, Inc

    305 Senter Ave, Whitehouse, TX 75791
    903 871-1172 fax 480-247-5650
    donself@donself.com web: www.donself.com
    free webinars at www.donself.com

    DISCLAIMER: This email should not pose any visual, auditory or sensory defects in the average reader. If you are now or have been dead or stupid in the past, this email will probably not help you. If you know anyone reading this email who is not from earth - you should immediately seek medical attention. If you have been or plan to be an imbecile in the future, please do not read this disclaimer. These warnings are not valid in the state of Hawaii, Alaska or New Hampshire.

  • edited May 2017
    Sorry - I replied to the other email before seeing this one. I apologize. OK - I see the problem.

    Medicare considers the patient inpatient for the entire day and do not believe that they should pay from part B for any supplies. So - they denied not only the supplies - but also the application code too?



    Don


    Don Self & Associates, Inc

    305 Senter Ave, Whitehouse, TX 75791
    903 871-1172 fax 480-247-5650
    donself@donself.com web: www.donself.com
    free webinars at www.donself.com

    DISCLAIMER: This email should not pose any visual, auditory or sensory defects in the average reader. If you are now or have been dead or stupid in the past, this email will probably not help you. If you know anyone reading this email who is not from earth - you should immediately seek medical attention. If you have been or plan to be an imbecile in the future, please do not read this disclaimer. These warnings are not valid in the state of Hawaii, Alaska or New Hampshire.

  • Yes, they denied both with a denial of "locked in".

    Kara L. Andrews, R.M.A.
    Practice Manager
    Gynecology of Venice, P.L.
    Orthopaedic Center of Venice, P.L.
    241 Nokomis Ave. S., Ste. A-B
    Venice, FL 34285
    941-485-9941/941-485-3302

  • edited May 2017
    He could be admitted in a SNF under a part A stay and if so under Consolidated billing rules they are responsible for paying you. Bill them.

    Marie Popkin, CPC
    Coding,Consulting & Compliance


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