Inpatient vs. Outpatient and Part B Inpatient Billing

Event Information
Product Format
Prerecorded Event
90 Minutes
Product Description

Know The Elements Of Inpatient And Outpatient Admission With Duane C. Abbey

Are you confused about how a physician determines that observation should be used rather than an inpatient admission? Or how condition code 44 should be used?

Join Duane C. Abbey, CFP, Ph.D in this 90-minute session that will discuss the confusion about whether a patient is an inpatient versus being an outpatient. When a patient is initially admitted as an inpatient, a determination may be made that the status should have been outpatient observation.  Condition Code 44 was developed to address this type of situation, but there has been significant controversy concerning the use of Condition Code 44 and Part A to Part B billing. Also, there is a situation in which a hospital will, after the patient is discharged, determine that the inpatient admission was not appropriate. CMS has developed rules and regulations to address this situation and the general issue of Part B inpatient billing.  

Duane will explain the Recovery Audit Contractors (RAC)s concerns about inpatient status, observation and possible recoupments, the difference between the ‘24-Hour’ Rule and the ‘Over 2-Midnights’ rule, and findings in cases such as the O’Connor Hospital Ruling. Discussions include Condition code 44, recent Federal Register discussions from CMS as well as the O’Connor Hospital appeal in this session. The program also includes the significant changes that CMS has made through the August 19, 2013, IPPS, Federal Register.

Objectives of the webinar: 

  • To discuss the issue of what constitutes an inpatient admission.
  • To review physician requirements for inpatient admissions versus outpatient observation admissions.
  • To briefly review inpatient admission criteria including CMS’s new ‘over 2-midnights’ rule.
  • To review the observation concept and payment for observation services.
  • To review various Medicare rules and regulations concerning observation services, including counting hours, Condition Code 44, and documentation requirements.
  • To appreciate how the Medicare interpretation of Condition Code 44 is different from private payer interpretations and usage.
  • To review the O’Connor Hospital Ruling from the Medicare Appeals Council.
  • To understand how CMS has reacted to the O’Connor Hospital Ruling and similar appeals.
  • To appreciate how CMS wants to address Part B inpatient billing as discussed in Federal Register entries.
  • To discuss the 1-year timely filing requirement.
  • To review CMS’s stance on the scope of review for federal auditors.
  • To discuss the Utilization Review Committee involvement in observation and for changes in inpatient status after the patient’s discharge.

Agenda of the webinar: 

  • Inpatient vs. Outpatient Status
    • Inpatient Admission Process
    • Medical Necessity Documentation
    • Standardized Inpatient Criteria
    • Compliance Issues
    • Payment Documentation
    • RAC Involvement
    • CMS’s Fundamental Premise
  • O’Connor Hospital Ruling
    • ALJ and MAC Rulings
    • Directives Made to CMS
    • CMS Acquiesce to the Rulings
  • August 19, 2013 Federal Register
    • CMS’s Fundamental Differences with Rulings
    • Ruling Making Process
    • Interim Rule – CMS-1455-R
    • Proposed Rule – CMS-1445-P
    • Transmittal 1247
    • Final Rules in IPPS for FY2014
  • Issues and Directives
    • Hospitals Are Solely Responsible For Correct Claims
    • Scope of Federal Auditors
    • Over 2-Midnights Rule
    • Part B Inpatient Billing
      • Conditions Code 44 Situations
      • Auditor Denial Situations
      • Hospital Self-Audit Situations
    • 1-Year Timely Filing Requirement
    • Categorization of Services Requiring Outpatient Status
  • CMS’s Conformance With Directives in the Rulings
  • Additional Issues and Concerns
    • Correcting Errors
    • Developing Payment Documentation
  • Case Studies and Exercises

Who should attend? The session is appropriate for outpatient nursing staff, medical/surgical nursing staff, nurse managers, ED nursing staff, utilization review personnel, quality assurance personnel, quality assurance personnel, physicians, coding personnel, billing and claims transaction personnel, chargemaster coordinators, financial analysts, compliance personnel, and other interested personnel.

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About Our Speaker

Duane Abbey Hospital Coding & Compliance Expert

 Duane C. Abbey, Ph.D. is a management consultant and president of Abbey & Abbey, Consultants, Inc., which specializes in healthcare consulting and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. He performs various types of financial analysis involving business structuring, organizational development, enrolment and other financially related concerns of organizations....   More Info
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