Beginning on or after June 25, 2010, the definition of “other services related to the
admission” (i.e., admission-related outpatient “nondiagnostic” services) is revised for
purposes of the 3-day (or 1-day) payment window policy.
For outpatient nondiagnostic services furnished on or after June 25, 2010, all outpatient
nondiagnostic services, other than ambulance and maintenance renal dialysis services,
provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on
the date of a beneficiary’s inpatient admission are deemed related to the admission, and
thus, must be billed with the inpatient stay. Also, outpatient nondiagnostic services, other
than ambulance and maintenance renal dialysis services, provided by the hospital (or an
entity wholly owned or wholly operated by the hospital) on the first, second, and third
calendar days for a subsection (d) hospital paid under the IPPS (first calendar day for nonsubsection
(d) hospitals) preceding the date of a beneficiary’s inpatient admission are
deemed related to the admission, and thus, must be billed with the inpatient stay, unless
the hospital attests to specific nondiagnostic services as being unrelated to the hospital
claim (that is, the preadmission nondiagnostic services are clinically distinct or
independent from the reason for the beneficiary’s admission) by adding a condition code 51
(definition “51 - Attestation of Unrelated Outpatient Non-diagnostic Services”) to the separately billed outpatient non-diagnostic services claim. Beginning on or after April 1,
2011, providers may submit outpatient claims with condition code 51 for outpatient claims
that have a date of service on or after June 25, 2010.
Hospitals must include on a Medicare claim for a beneficiary’s inpatient stay the
diagnoses, procedures, and charges for all preadmission outpatient diagnostic services and
all preadmission outpatient nondiagnostic services that meet the above requirements. For
purposes of the Present on Admission Indicator (POA), even if the outpatient services are
bundled with the inpatient claim, hospitals shall code any conditions the patient has at the
time of the order to admit as an inpatient as POA irrespective of whether or not the patient
had the condition at the time of being registered as a hospital outpatient. In combining on
the inpatient bill the diagnoses, procedures, and charges for the outpatient services, a
hospital must convert CPT codes to ICD procedure codes and must only include outpatient
diagnostic and admission-related nondiagnostic services that span the period of the
payment window
Outpatient nondiagnostic services provided during the payment window that are unrelated
to the admission and are covered by Part B may be separately billed to Part B. Hospitals
must maintain documentation in the beneficiary’s medical record to support their claim
that the preadmission outpatient nondiagnostic services are unrelated to the beneficiary’s
inpatient admission.
Effective for dates of service on or after June 25, 2010, CWF will reject outpatient claims
for nondiagnostic services when the following occurs:
1) Condition code 51 (definition “51 - Attestation of Unrelated Outpatient Nondiagnostic
Services”) is not included on the outpatient claim, and
2) The line item date of service (LIDOS) falls on the day of admission or any of
the 3 days immediately prior to an admission to an IPPS hospital (or on the day of
admission or one day prior to admission for hospitals excluded from IPPS).
Billing Procedures to Avoid Duplicate Payments
HO-400H
The hospital must install adequate billing procedures to avoid submission of duplicate
claims. This includes duplicate claims for the same service and outpatient bills for
nonphysician services considered included in the DRG for a related inpatient admission in
the facility or in another hospital.
Where the hospital bills separately for nonphysician services provided to a patient either
on the day before admission to a PPS hospital or during a patient's inpatient stay, the claim
will be rejected by the A/B MAC (A) as a duplicate and the hospital may be subject to
sanction penalties per §1128A of the Act.
No comments:
Post a Comment