Answer to Question 1
Answer:
The provider of service is a facility that provides inpatient care. This may be a hospital, an acute care facility, a skilled nursing facility, a custodial care facility, or a similar facility.
For inpatient care, the patient must be admitted into the hospital and stay for a period of time, usually a minimum of 24 hours. There must be a room and board charge. A hospital room and board charge is similar to that for staying in a hotel. The day entered is paid but not the day discharged, as long as the discharge time is before the required checkout time. The UB-04 form should always indicate admission and discharge dates.
When coding inpatient hospital claims, the CPT or RVS books are not used unless the billing has itemized some charges according to valid CPT/RVS codes. Each payer has its own coding guidelines. Therefore, before a claim can be coded for processing, the payer-specific codes must be obtained. Most payers break up the bills according to:
Room and board charges
Ancillary charges
Take-home prescriptions
Professional fees for exams, surgery, etc.
Answer to Question 2
Answer:
Two things to be considered are:
a. Reasonableness. This evaluates the soundness and practicality of the DME approach to therapy, including such factors as:
1. Is the need for the unit based on failures of other, less costly approaches? For example, if the patient tried an inexpensive transfer board and was unsuccessful, then a trapeze which is more expensive would be a better option for the patient to transfer himself out of the bed.
2. Have more conservative means been attempted? Conservative relative to DME is something like using a hot pack for muscle relaxation versus a less conservative method of an electrical stimulation unit.
3. What benefits will be derived from the unit? If DME will bring the patient's functioning back to the previous level, it is usually considered beneficial. However, if the equipment is just a trial, but not likely to really progress the patient along in functioning, it isn't considered a benefit.
4. Do the benefits justify the expense?
b. Necessity. Equipment is necessary when it is expected to make a meaningful contribution to the treatment of the patient's illness or injury or to the improvement of the functioning of a malformed body part. Physicians tend to prescribe equipment based on a variety of reasons including:
1. Familiarity. The physician is familiar with a particular piece of equipment. Other less expensive, more effective means of treatment or equipment may be available.
2. Current popularity. As with clothing fashions, treatment and equipment popularity runs in cycles. Patients may even request the use of some pieces of equipment because it is hyped by the news media or some other medium. The particular equipment may not be the best or least expensive treatment available.
3. Monetarily beneficial. Some equipment suppliers provide monetary inducements to physicians who use their equipment. Therefore, some physicians may routinely prescribe certain equipment based on this factor.
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