Payment Window for Outpatient Services Treated as Inpatient

10.12 - Payment Window for Outpatient Services Treated as Inpatient Services (Rev. 3238, Issued: 04-22-15, Effective: 04-01-15 Implementation: 04-06-15) The policy for the payment window for outpatient services treated as inpatient services is discussed in chapter 3 § 40.3 of this manual. The policy requires payment for certain outpatient services provided to a beneficiary on the date of an inpatient admission or during the 3 calendar days (or 1 calendar day for a non-IPPS hospital) prior to the date of an inpatient admission to be bundled (i.e., included) with the Medicare Part A payment for the beneficiary’s inpatient admission if those outpatient services are provided by the admitting hospital or an entity that is wholly owned or wholly operated by the admitting hospital. The policy applies to all diagnostic outpatient services (including non-patient laboratory tests) and non-diagnostic services (i.e., therapeutic) that are related to the inpatient stay. Ambulance and maintenance renal dialysis services are not subject to the payment window. All diagnostic services (including non-patient laboratory tests) provided to a Medicare beneficiary by a hospital (or an entity wholly owned or wholly operated by the hospital) on the date of the beneficiary’s inpatient admission or during the 3 calendar days (or, in the case of a non-subsection (d) hospital, 1 calendar day) immediately preceding the date of admission are required to be included on the Part A bill for the inpatient stay. Outpatient non-diagnostic services that are related to an inpatient admission must be bundled with the Part A billing for the inpatient stay. An outpatient service is related to the admission if it is clinically associated with the reason for a patient’s inpatient admission. In accordance with section 102 of Pub. L. 111-192, for services furnished on or after June 25, 2010, all outpatient non-diagnostic 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 to Part A with the inpatient stay. Also, outpatient non-diagnostic 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 non-subsection (d) hospitals) preceding the date of a beneficiary’s inpatient admission are deemed related to the admission, and thus, must be billed to Part A with the inpatient stay, unless the hospital attests to specific non-diagnostic services as being unrelated to the hospital claim (that is, the preadmission non-diagnostic services are clinically distinct or independent from the reason for the beneficiary‘s admission). Outpatient non-diagnostic 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. The June 25, 2010 effective date of section 102 of Pub. L. 111-192 applies to outpatient services provided on or after June 25, 2010. In the event that there is no Part A coverage for the inpatient stay, the hospital may bill Part B for the services provided to the beneficiary prior to the point of inpatient admission (i.e., the time of formal admission pursuant to the inpatient admission order) that would otherwise be included in the payment window for Part A payment, including services requiring an outpatient status. Certain Part B inpatient services provided to the beneficiary after the point of inpatient admission (i.e., the time of formal admission pursuant to the inpatient admission order) may also be billed to Part B when Part A payment cannot be made. See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §10 “Medical and Other Health Services Furnished to Inpatients of Participating Hospital" for a full description of this policy. A hospital may attest to specific non-diagnostic services as being unrelated to the hospital Part A claim (that is, the preadmission non-diagnostic 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. Providers may submit outpatient claims with condition code 51 starting April 1, 2011, for outpatient claims that have a date of service on or after June 25, 2010. Outpatient claims with a date of service on or after June 25, 2010, that did not contain condition code 51 received prior to April 1, 2011, will need to be adjusted by the provider if they were rejected by FISS or CWF.