Or. Admin. Code § 410-125-0360 - Definitions and Billing Requirements
(1) Total days on an inpatient claim must
equal the number of accommodation days. Do not count the day of discharge when
calculating the number of accommodation days.
(2) Inpatient services are reimbursed based
on the admission date and discharge diagnosis.
(3) Inpatient services are services to
patients who typically are admitted to the hospital before midnight and listed
on the following day's census, with the following exceptions:
(a) A patient admitted and transferred to
another acute care hospital on the same day is considered an inpatient;
(b) A patient who expires on the
day of admission is an inpatient; and
(c) Births.
(4) Outpatient services:
(a) Outpatient services are services to
patients who are treated and released the same day;
(b) Outpatient services also include services
provided prior to midnight and continuing into the next day if the patient was
admitted for ambulatory surgery, admitted to a birthing center, a treatment or
observation room, or a short term stay bed;
(c) Outpatient observation services are
services provided by a hospital, including the use of a bed and periodic
monitoring by hospital nursing or other staff for the purpose of evaluation of
a patient's medical condition. A maximum of 48 hours of outpatient observation
shall be reimbursed. An outpatient observation stay that exceeds 48 hours shall
be billed as inpatient; and
(d)
Outpatient observation services do not include the following:
(A) Services provided for the convenience of
the patient, patient's family or physician but that are not medically
necessary;
(B) Standard recovery
period; and
(C) Routine
preparation services and recovery for diagnostic services provided in a
hospital outpatient department.
(5) Outpatient and inpatient services
provided on the same day: If a patient receives services in the emergency room
or in any outpatient setting and is admitted to an acute care bed in the same
hospital on the same day, combine the emergency room and other outpatient
charges related to that admission with the inpatient charges. Bill on a single
UB-04 for both inpatient and outpatient services provided under these
circumstances:
(a) If on the day of
discharge, the client uses outpatient services at the same hospital, these
shall be billed on the UB-04 along with other inpatient charges, regardless of
the type of service provided or the diagnosis of the client. Prescription
medications provided to a patient being discharged from the hospital may be
billed separately as outpatient Take Home Drugs if the patient receives more
than a three-day supply;
(b)
Inpatient and outpatient services provided to a client on the same day by two
different hospitals shall be reimbursed separately. Each hospital shall bill
for the services provided by that hospital;
(c) Inpatient and psychiatric emergency
services (PES) as defined in OAR
309-023-0110 provided to the
patient on the same day, whether in the same hospital or two different
hospitals, shall be reimbursed separately.
(6) Outpatient procedures that result in an
inpatient admission: If, during the course of an outpatient procedure, an
emergency develops requiring an inpatient stay, place a "1" in the Type of
Admission field. The principal diagnosis should be the condition or
complication that caused the admission. Bill charges for the outpatient and
inpatient services together.
Notes
Forms referenced are available from the agency.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
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