Do you keep them under inpatient status? Or do you bring them in as outpatients and just keep them overnight?
For our Medicare populations, in all of our organizations, the ability to follow the CPT code of the applicable surgical procedure is the determining factor to bill inpatient surgeries correctly. We are probably not alone in that, over the years, a few patients have had surgery and were discharged from the recovery area, only to find out later that the procedure included a CPT code on the inpatient-only list. This happens because not all of the team members involved speak in coding language. It is a pretty significant loss when you cannot recuperate the costs of those cases.
On the other side of that coin, those patients who are brought in for an outpatient procedure that we provide care for overnight can be just as big of a financial drain on your system. And while I always advocate for doing what is right for the patient in your care, we all know that getting reimbursed for that care is tantamount to keeping your doors open for the next patient.
Let’s review what has been happening. I am going to use my favorite procedure, total hip replacements, for this review. And I will say in this case we’re talking about elective procedures, not fractures. Up until 2019, these procedures were on the inpatient-only list. Some traditional insurances began pushing for outpatient status prior to this, but let’s stick with 2019. What was your reaction to the change? Did you keep them under inpatient status? Or did you bring them in as outpatients and just keep them overnight?
Most of our hospitals already had what was called “joint camp,” a process to have these patients come to a class prior to the elective procedure and assess them physically, then prepare them for a short stay in the hospital. That was prior to 2019. Some of our organizations were so adept at it that those patients were in and out overnight in about 20 hours, or at the most, 36 hours. The rehabilitation department was on board, and the teams used a really well-honed process. Some places could even close those units by Friday afternoon and start back up on Monday morning.
But now, what has happened? Well, for most, the same process is used. But there is absolutely not the same reimbursement. Did the care change? No – a big, resounding no. Did the cost change? One could argue that if you limit the prosthetic choice to a few of them, you could affect the cost a bit, but the same nurses, PCTs, therapists, diet aides, housekeepers, maintenance workers, and transporters are all still used in this now very expensive outpatient stay. Oh, and if your contribution margin on these is as low as some of ours are, you are paying for these, not getting paid for them.
There are other outpatient procedures going this way as well. And again, I advocate for safe care, but do all of your patients need to stay overnight? Just think about this from the patient’s point of view for a second. It involves going back to their own home, with no call lights and no noise in the middle of the night. Yes, they need support, but does it have to be nursing? So, what do we do? I have to give a shout-out to my friend Julie here, as I think they have figured it out. They are providing the surgery and all of the rehabilitation for these patients on dedicated days of the week so that everyone is ready to rehabilitate and educate – and they discharge the same day. This can make for a long day for your therapists, because that department is really used to eight-hour days, but if you do it correctly, you can probably add an extra afternoon shift on those dedicated days. What a great idea that is – and one I will be spreading in our organizations. That is forward thinking!
As you may recall, last week I critiqued a webinar on the two midnight rule. As you will recall it was not pretty. Today I
It is all too common for patients and physicians to take to social media to air grievances about insurance company misdeeds. A recent case generated
Please log in to your account to comment on this article.
Physician queries are essential for accurate documentation and claims data, but they are increasingly scrutinized by payors, leading to denials and revenue leakage. This webcast, led by industry expert Cheryl Ericson, RN, MS, CCDS, CDIP, provides actionable strategies to craft compliant queries, reduce denials, and enhance revenue integrity. Attendees will gain insights into clinical validation queries, how to avoid common pitfalls, and learn best practices to defend against query denials. Don’t miss this opportunity to refine your query process and protect your organization’s financial health.
Master the complexities of heart failure coding with this expert-led webcast by Emily Montemayor, CCS, CMBCS, COC, CPC, CPMA. Discover strategies to ensure compliance with ICD-10-CM guidelines, documentation integrity, and capture comorbidities like CKD and hypertension. Learn how to resolve coding challenges, improve documentation practices, and submit clean claims to minimize denials and safeguard your organization’s financial health. With practical insights and real-world examples, this session equips you to prevent revenue leakage, enhance compliance, and secure optimal reimbursement—all while supporting better patient outcomes.
Prepare your organization for the 2025 OPPS updates with expert insights from Tiffani Bouchard, CCS, CRCR, a Revenue Integrity Professional with over 30 years of experience. This webcast will address critical challenges in charge capture and coding, providing clarity on APC policies, C-APC packaging, exclusions, and payer-specific requirements. Attendees will learn actionable strategies to ensure compliance, optimize reimbursement, and mitigate risks of claim denials. Gain the knowledge needed to implement updates effectively, educate your team, and maintain seamless revenue cycle operations in the face of evolving OPPS complexities.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Dr. Ronald Hirsch dives into the basics of Medicare for clinicians to be successful as utilization review professionals. He’ll break down what Medicare does and doesn’t pay for, what services it provides and how hospitals get paid for providing those services – including both inpatient and outpatient. Learn how claims are prepared and how much patients must pay for their care. By attending our webcast, you will gain a new understanding of these issues and be better equipped to talk to patients, to their medical staff, and to their administrative team.
Hospitals face growing challenges in measuring observation metrics due to inconsistencies in classification, payer policies, and benchmarking practices. Join Tiffany Ferguson, LMSW, CMAC, ACM, and Anuja Mohla, DO, FACP, MBA, ACPA-C, CHCQM-PHYADV as they provide critical insights into refining observation metrics. This webcast will address key issues affecting observation data integrity and offer strategies for improving consistency in reporting. You will learn how to define meaningful metrics, clarify commonly misinterpreted terms, and apply best practices for benchmarking, and gain actionable strategies to enhance observation data reliability, mitigate financial risk, and drive better decision-making.
The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Copyright © 2025 RACmonitor. Powered by MedLearn Media.
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 →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
