Outpatient in a Bed – Compliance is Key

Outpatient in a Bed – Compliance is Key

Today I am going to do something a little different. I am going to write about outpatient care in a bed from the regulatory side, and then Tiffany Ferguson is going to address operationalizing it in a separate article in Tuesday’s ICD10monitor.

But first, a bit of news. First, never doubt the power of one person. Some of you may have heard of Richelle Marting, a healthcare lawyer from Missouri who spoke at the National Physician Advisor Conference. Well, one of her clients recently had a problem. They were being denied payment for a specific type of bariatric surgery because the claim did not clear the coding edits. The problem was that the surgery was being done laparoscopically, but the National Coverage Determination (NCD) required three codes describing the surgery, and one of the three had to be a code for an open surgery. It made no sense at all. But Richelle got to work and got the Centers for Medicare & Medicaid Services (CMS) to change the rules, and they even made it retroactive to 2020! Congratulations, Richelle.

Second, none of us like prior authorizations, especially physicians who are simply trying to care for their patients. And by now you all should have heard about the recent audits by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) that found that Medicare Advantage (MA) plans were using prior authorizations to deny care to beneficiaries that would have been covered if they were enrolled in traditional Medicare. Well, the OIG tweeted about a recent “Impact Brief” they published on this issue.  And that’s great; the more attention to the issue, the better. But what irked me was that the tweet stated “prior authorization requirements in Medicare Advantage occasionally obstructed enrollees’ access to vital services.” Occasional??? More than 13 percent of denials were inappropriate. That’s not occasional. That’s frequent, and that’s way too much so. OIG, do better.

Now, about outpatient in a bed. This came back up with a recent post on RAC Relief wherein someone asked if outpatient in a bed requires a physician order. My response, as some of you probably could have predicted, was that outpatient in a bed is not a real thing. What I then explained was that outpatient in a bed is not a real admission status; a patient is either an inpatient or an outpatient. I won’t go through the requirements to be an inpatient but suffice to say that any patient who has not met the requirements to be an inpatient is an outpatient.

But the real reason many people ask about outpatient in a bed is that they have patients in the hospital who don’t require hospital care, and they want to separate them from those with medical necessity for payment and tracking purposes. So, a few tips.

First, I occasionally hear that a patient having outpatient surgery should always go home the same day. That’s not true. While we are getting much better at optimizing care, there are many outpatient surgeries for which an overnight stay is absolutely the standard of care in select patients. Those patients should not be lumped in with the outpatient who is staying overnight because it is starting to snow or they cannot get a ride. Now, feel free to name this sub-status anything you want; many use the term “extended recovery,” but the key is that they are outpatients, their care is not custodial, and that recovery time should be billed as recovery services, not as “outpatient in a bed” hours.

Second, once an inpatient, always an inpatient. Unless you are a rural or critical access hospital and your inpatient is transitioning to a swing bed, an inpatient remains an inpatient until they either die or are formally discharged. You cannot discharge a patient from inpatient care when their acute care is completed and then create an outpatient encounter for the custodial care. We wish you could, so you could get paid separately for ancillary services, but you can’t. Rather, you should leave them as inpatients and work with your billing staff to apply the correct occurrence span code to the days that are not necessary.

So, if outpatient in a bed is not real, does that mean it’s prohibited? Nope; feel free to use it for the patient staying because it’s snowing or waiting for a ride or waiting for the family to get back from Disney World. But as Tiffany will discuss tomorrow, the key is to ensure that when it is ordered, there is communication between the clinical and the finance teams, so when these outpatients without medical necessity are in the hospital, everyone knows – and the hours and days are properly tracked and action can be taken to minimize giving away all this free care.

In addition, as I noted, “outpatient in a bed” is not a real service, as are observation services or recovery room services. And as such, it does not require an order. In fact, the outpatient who is hospitalized, be it a surgical patient whose in-hospital recovery has ended, an outpatient receiving observation services whose need for hospital care has ended, or a patient being hospitalized from the ED for custodial care, can have their care be designated as “outpatient in a bed” by the case manager, the bedside nurse, the physician, or even the compliance officer. If hospital care is not needed, the care should not be billed as necessary care.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

The Inpatient Admission Order: Master the Who, When, and How

The Inpatient Admission Order: Master the Who, When, and How

During this webcast Dr. Ronald Hirsch delves into the inpatient admission order process including when to get it, when it becomes effective, its impact on billing and payment, who can write it, how to cancel it, the effects on the beneficiary, and more. You’ll leave with a clear understanding of inpatient orders and guidelines for handling improper orders that you can implement immediately.

June 20, 2024
Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Navigating AI in Healthcare Revenue Cycle: Maximizing Efficiency, Minimizing Risks

Michelle Wieczorek explores challenges, strategies, and best practices to AI implementation and ongoing monitoring in the middle revenue cycle through real-world use cases. She addresses critical issues such as the validation of AI algorithms, the importance of human validation in machine learning, and the delineation of responsibilities between buyers and vendors.

May 21, 2024
Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Optimize your inpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. Participants will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

June 26, 2024
Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Advanced Inpatient Clinical Documentation Integrity: Harnessing Technology, Analytics, and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P., as she helps you navigate advanced inpatient CDI technologies, regulatory changes, and system interoperability. Angela will provide actionable strategies for integrating AI and predictive analytics into CDI practices, ensuring seamless system interoperability, and maintaining compliance with evolving regulations. Attendees will learn to select and implement advanced EHR systems and CDI software, leverage data analytics to enhance documentation accuracy, and stay audit-ready with the latest compliance updates. Real-world case studies and practical tools will empower you to drive continuous improvement in CDI, improve patient outcomes, and enhance organizational efficiency. Don’t miss this opportunity to advance your CDI practices and stay ahead in this dynamic field.

July 11, 2024
Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Foundations of Inpatient Clinical Documentation Integrity: Enhancing Accuracy and Compliance

Join expert Angela Comfort, MBA, RHIA, CDIP, CCS, CCS-P, for an insightful webcast on improving inpatient clinical documentation integrity (CDI). Inaccurate documentation can lead to misdiagnosis, improper treatment, and compromised patient safety. High workloads, lack of standardized practices, and outdated EHR systems contribute to these issues, affecting care quality and financial outcomes. Angela will offer practical strategies and tools to enhance accuracy, consistency, and timeliness in documentation. Attendees will learn to use standardized templates, checklists, and advanced EHR systems, while staying compliant with regulations. Improve patient care, ensure accurate billing, and reduce audit risks with actionable insights from this essential webcast.

June 26, 2024
Mastering E/M Coding: Navigating the Evolving Landscape

Mastering E/M Coding: Navigating the Evolving Landscape

Join industry expert, Kathy Pride, RHIT, CPC, CPMA, CCS-P, for an in-depth exploration of Evaluation and Management (E/M) coding, tailored for healthcare professionals navigating recent guideline changes. Dive into advanced topics beyond mere code selection, including shared visits, criteria for selecting E/M levels, and documentation best practices. Gain clarity on complex guideline terminology and ensure compliance with regulatory standards. This comprehensive session is essential for coders, auditors, educators, and practitioners seeking to enhance their proficiency in E/M coding and maximize revenue capture.

June 19, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

Honor Memorial Day with Savings! Get 20% off all items using code MEMORIAL24 at checkout. Shop today and save! Offer valid until May 31. Exclusions apply.

Happy World Health Day! Our exclusive webcast, ‘2024 SDoH Update: Navigating Coding and Screening Assessment,’  is just $99 for a limited time! Use code WorldHealth24 at checkout.