Stream: CARIN IG for Blue Button®
Topic: EOB - Differentiating Between Inpatient and Outpatient
Joel Hansen (Aetna) (Jul 08 2020 at 17:31):
Hi All,
We have some claims types that could be either considered either inpatient or outpatient claims. For these claim types, we are coming up with a best approach of how to include them in the various CARIN EOB profiles (either Inpatient or Outpatient). We are considering looking at other claim criteria, like the Beginning Date of Service and Ending Date of Service. If the dates are the same we would consider it as an Inpatient else it would be an Outpatient.
I just wanted to check with the group if others are having similar issues classifying inpatient vs. outpatient and what approaches are being used?
Thank you,
Joel
Jason Teeple (Jul 08 2020 at 19:36):
@Joel Hansen (Aetna) , wouldn't your claim systems make the classification based on the benefits of a plan? I could be misunderstanding your question.
Amol Vyas (Jul 14 2020 at 10:53):
@Joel Hansen (Aetna) , do the claims in question have DRG codes? Does the latest CARIN BB profile comparison here help?
Joel Hansen (Aetna) (Jul 15 2020 at 20:51):
@Amol Vyas Thank you for the suggestion on DRG codes and the link to the profile comparison. We will look in to the DRG codes as a potential approach.
To provide more details on one of the situations we're encountering: BillType 12x is an outpatient bill type, however there is something called an accommodation code that when use indicates a 'bed day' was required for the outpatient service and therefore it needs to be billed as an inpatient claim.
Ryan Harrison (Oct 07 2020 at 17:25):
The question remains, how do we reliably distinguish between Inpatient (IP) and Outpatient (OP) [^1]?
For example, if I were to view an EOB IP and EOB OP side-by-side, without meta.profile 0..*...
| Element | Card | C4BB version | Note |
|---|---|---|---|
| supportingInfo:admissionperiod | 0..1 | v0.1. | |
| supportingInfo:admtype | 0..1 | v0.1.3 | Claim Priority (Type) of Admission or Visit " |
| supportingInfo:drg | 0..1 | v0.1.3 | |
| item.revenue | 0..1 | v0.1.3 | "This Element must be supported" |
| item.detail.revenue | 0..1 | v0.1.3 | |
| item.detail.subDetail.revenue | 0..1 | v0.1.3 | |
| diagnosis.onAdmission | 0..1 | v0.1.2. | Removed in v0.1.3 |
All of the distinguishing elements are optional.
To @Amol Vyas's suggestion, supportingInfo:drg would work -- if it is returned -- which is not required.
To @Pat Taylor's suggestion for using revenue codes would work if
i)*They are returned, which is also not required.
ii) Unlike mere existence with drg (if drg, then IP), here we'd have to map revenue code to IP vs OP (I suspect some codes can be used for both).
iii) NUBC Requires separate licence
[^1] Recall that we can distinguish Professional, Pharmacy and Institutional (IP and OP) from the C4BB required element type.coding (http://terminology.hl7.org/CodeSystem/claim-type), so the problem is restricted to IP vs OP.
@Pat Taylor
- https://chat.fhir.org/#narrow/stream/204607-CARIN-IG.20for.20Blue.20Button.C2.AE/topic/ExplainationOfBenefit-Inpatient-Facility.2Eitem.2Erevenue
- https://jira.hl7.org/browse/FHIR-26849 (Bind NUBC Priority Type Of Admission Or Visit to the Outpatient Facility Profile ).
- NUBC is used for
supportingInfo:admtype(https://build.fhir.org/ig/HL7/carin-bb/branches/v0.1.3/ValueSet-AHANUBCPriorityTypeOfAdmissionOrVisit.html)
- NUBC is used for
@James Fadeley
Michele Mottini (Oct 07 2020 at 17:39):
ExplanationOfBenefit.type is not optional and it should say if it is inpatient (institutional) or not (?)
Pat Taylor (Oct 07 2020 at 20:25):
@Ryan Harrison From a server perspective, payers should have logic that defines the nuances between inpatient and outpatient institutional claims; for example, overnight observations are typically an outpatient claim. The determination would be made as payers adjudicate claims as the reimbursement methodologies and benefits applied are typically different. The two profiles were separated due to the differences in value set binding requirements; for example, inpatient requires ICD procedure codes and DRGs; outpatient does not. @Michele Mottini The EOB.type values align with those defined by HL7. Do requestors need to differentiate between the two institutional data they receive? If so, a recommendation would be to define a subtype with fixed values inpatient institutional and outpatient institutional respectively for the two profiles. @Amol Vyas @Joel Hansen (Aetna) @Jason Teeple
Michele Mottini (Oct 07 2020 at 20:32):
As a client we do not need that distinction, the only distinction we need is between pharmacy claim and everything else
Last updated: Apr 12 2022 at 19:14 UTC
