- Currently most hospital admissions are through the emergency room, same day (the morning of a procedure), or ambulatory admissions (no overnight stay)
- Insurance companies must be notified of all admissions even emergency
- The Admitting Office along with your physician’s office confirms with your insurance company that you are covered for the admission.
- Precertification the process where the insurance company approves the admission
- ICD-10 and CPT codes are the numerical description provided by your physician that tells your insurance company and the hospital your diagnosis and procedure
- Speak to your insurance company yourself to protect your interests and be prepared to work your way through their bureaucracy.
- Upon admission, make sure all the admitting office has all your information correct including your diagnosis and procedure!
In the not so recent past, the first stop any patient made in the hospital was in the admitting room. Today it is just as common for a patient to be admitted through the operating room floors for a same day admission, or from the emergency room. The admitting office, however, remains the gateway to the business side your hospital admission.
What is a Preadmission Form?
In the case of an elective medical or surgical admission, your doctor’s office will fill out the preadmission form and send it to the hospital.
Your preadmission form will contain your medical diagnosis and the code (ICD-9) that identifies it to your insurance company. If you are having surgery or another procedure, the procedure codes (CPT) will similarly be included. The form also contains your demographic and other identifying information, along with relevant financial and insurance information. Once received the hospital will contact your insurer to confirm your coverage and allowed length of stay.
What’s the difference between Precertification and Preadmitting?
While the hospital is in the preadmission phase, your insurance company is performing “precertification”. Most insurers expect to be informed 48 hours before non-emergency procedures. Your doctor’s office will usually do this, but you should confirm with your insurance carrier that they have been contacted.
In addition to your plan and policy number, the insurer will need to know your diagnosis and the treatment your doctor will conduct when you are admitted. When approved you will get a precertification, certification or an approval number. Unfortunately, none of these is a guarantee of coverage and the insurance carrier reserves the right to review your actual admission data after discharge to confirm coverage.
In emergency admissions there is obviously not sufficient time to get precertification. Don’t worry! Patients requiring emergency care cannot be denied treatment because of a lack of precertification or insurance coverage.
Why should I care about CPT and ICD-9 Codes?
These codes are how hospitals, doctors and insurers communicate without having to write it all out. The CPT is common procedure terminology code and the ICD-9 is the International Classification of Disease, 9th revision. Both are comprise abbreviations and numbers that identify your diagnosis, and recommended treatment or procedure.
It is in the hospital’s best interest to make sure that both codes match—i.e. the CPT for gallbladder removal matching the ICD-9 for an inflamed gallbladder. Mismatched codes will lead to denial of a claim that ultimately falls back on you. Both hospital and doctor run the risk of not being paid for a service that is normally covered if a code is not applied properly. In order to maximize proper reimbursement, hospitals employ special workers solely to verify the accurate input and application of these codes.
Where and when will preadmission testing take place?
Preadmission testing has changed over the years due to the influence of insurers. There was a time when patients were admitted to hospital a full day before a procedure to perform testing, and to ensure readiness for an upcoming procedure. However, one less day in the hospital for the same procedure improves the insurance company’s bottom line. As a result, the number of elective, traditional admissions has declined and ambulatory admissions have increased. Whether or not this has adversely affected the quality of care is another issue.
Most preadmission testing is now done in the two-week period prior to the procedure. It is advisable to schedule testing as early as the hospital will allow, so that there is sufficient time for tests to be repeated or other actions taken.
What should I expect the day before admission?
You will receive a call telling you what time to report for your procedure. You should keep in mind how hospitals operate: believe it or not, there is a fine line between being solvent or insolvent. Therefore, all hospitals try to operate at 100% capacity. Anything less and the hospital struggles to remain profitable. If planned discharges are delayed or emergencies occur, there is a possibility that no bed will be available for you. In situations like that, patients have stayed overnight in the recovery room after surgery, in the emergency room, or, in the rarest of circumstances, have been bumped!
What happens when I get to the admitting office?
Admitting offices are crowded and hectic, and you’ll—of course—be nervous. Fortunately, some of the hospital’s friendliest workers are placed in the admitting office for just this reason.
You will receive an identification bracelet that has your pertinent information and lets all staff know who you are. Your name and information is listed on every piece of paper (or digital document) that relates to your stay. These practices ensure that you will get the procedure you are supposed to receive, that your test results are properly recorded, and that you receive the proper medication.Leave a reply →