Outpatient and Emergency Room Services

Outpatient Charges Related to an Inpatient Admission     

Emergency Room Visit Leading to an Inpatient Admission   

If the patient is seen in the emergency room within 24 hours of an inpatient admission for the same diagnosis, the charges for the emergency room should be included on the inpatient claim. 

Include outpatient charges on the UB04 as part of the inpatient billing.       

Multiple visits – same day 

If a patient visits the emergency room more than once on the same day, the visits can be rolled into one if the reason for the visit was the same diagnosis. If each visit was caused by a different diagnosis, bill the charges separately.   

Non-emergent and scheduled admissions 

Include any outpatient services related to the same condition and reason for the admission that was provided within 24 hours prior to the inpatient admission as part of the inpatient billing.       

A4649 billed on an outpatient facility claim will be denied as inclusive.     

Note: Critical Access Hospitals may bill the ER charges separately from the inpatient claim.   

Observation

Observation services refers to the period of treatment:

• When the physician is evaluating the patient’s medical condition to determine whether the patient can be released from the outpatient department or admitted to the facility as an inpatient or transferred to another facility OR
• Following an outpatient procedure when the physician is evaluating the patient’s medical condition to determine whether the patient can be released from the outpatient department.       

A physician must justify and provide the order on the patient. Medical record documentation must prove that the patient was admitted to observation.    

BCBSNE follows the Medicare definition, which requires the use of a bed and nursing services.   

   Observation is NOT:    

• A substitute for an inpatient admission    
• For continuous monitoring    
• For medically stable patients who need diagnostic testing or outpatient procedures    
• For patients who routinely need therapeutic procedures provided in an outpatient setting    
• For patients waiting for nursing home placement    
• To be used as a convenience to the patient, his or her family, the hospital or the attending physician    
• For routine prep or recovery prior to or following diagnostic or surgical services     

Also, note the following:    

• Revenue code 761 is for a treatment room and should not be used in place of an observation room.    

Observation services will be paid as an outpatient service type under the outpatient provider contract provisions.    

Observation should be billed all on one line (even when it is spread across two dates). Ex: Patient is under 24 hr. observation. They come in at 1 p.m. on June 1 and are released at 1 p.m. on June 2. This should be billed on one line, not on two separate lines.    

NOTE: Revenue Code 769 is not valid for reporting observation services and will be returned for proper coding   

Inpatient Following Observation  

• Bill observation services that convert to an inpatient admission on the same UB-04 form as the inpatient admission.  
• Enter the outpatient observation admission date in Form Locator 6 as the beginning (from) date of the UB-04 form.   
• Enter the date on which the patient was admitted for inpatient services in Field Locator 12  
• Enter the time at which the patient was admitted for inpatient services in Field Locator 13; hours are entered in two-digit military time (e.g., use 14 for 2:00 p.m.)