Q&A: Patient and provider notice of a change in status
Q. On Mondays, the facility where I work performs a self-audit on one- and two-day admissions that occurred over the weekend. We do this before the bill is dropped. If we find that an inpatient admission should have observation or outpatient, the billing department uses the appropriate codes for the claim and bills for Medicare Part B. Should we notify the patient of this change? Do we need to involve the physician who wrote the order?
A. From your question, I wasn’t clear if the patient was still at the facility or had been discharged, so I’ll address both situations. The answer is essentially the same because both situations rely on the same utilization review (UR) Condition of Participation (CoP).
The CoP for UR determinations must be followed any time an inpatient admission is not billed for Part A payment, but rather is billed for Part B payment on Type of Bill (TOB) 131 after concurrent review and the status is changed to outpatient while the patient is still at the hospital (with condition code 44). The CoP must also be followed for Part B payment on TOB 121 after post discharge review (with condition code W2).
See the Medicare Claims Processing Manual, Chapter 1, Section 50.3, and MLN Matters Article SE0622 for a discussion of the requirement of a UR determination for condition code 44. See 42 CFR 414.5 for the specific requirement of a UR determination to obtain Part B payment for post-discharge review.
The UR determination CoP is 42 CFR 482.30(d) and in the event of a status change it requires the involvement of at least one physician UR committee member, the opportunity for the attending physician to provide input if he or she desires, and notice to the patient and attending physician within two days. In the case of condition code 44, CMS has provided further guidance that the attending physician must not only have the opportunity to provide input, but also must concur with the status change and document that concurrence in the patient’s medical record. Additionally, CMS requires that notice be provided to the patient before he or she is discharged from the hospital.
In the case you describe, you must provide notice to the patient either before discharge if you wish to change his or her status and bill with condition code 44 as outpatient or within two days if you have made the determination after discharge. The attending physician would have to concur in the case of a change using condition code 44, but would only have to be provided the opportunity to offer input if the determination is made after discharge. The patient would also have to receive notice within two days of a post-discharge determination.
Editor’s note: This question was answered by Kimberly Anderwood Hoy Baker, JD, CPC, is the director of Medicare and compliance for HCPro, a division of BLR, in Middleton, Massachusetts.
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