CMS offers correct billing tips for nonphysician outpatient services provided before or during inpatient stays

Health Care Compliance Association (HCCA)
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Health Care Compliance Association (HCCA)

Compliance Today (March 2021)

The Centers for Medicare & Medicaid Services (CMS) has provided the following compliance notice:[1] “In a recent report,[[2]] the Office of Inspector General (OIG) determined that Medicare made incorrect payments for non-physician outpatient services provided shortly before or during inpatient stays. Review the FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients (PDF)[[3]] MLN Matters Article to bill correctly for these services. Additional resources:

  • “Medicare Benefit Policy Manual, Chapter 6 (PDF), Section 20.4[[4]]

  • “Medicare Claims Processing Manual, Chapter 12 (PDF), Sections 90.7, 90.7.1[[5]]

  • “CY 2012 Medicare Physician Fee Schedule Final Rule[6]

  • “Medicare Does Not Pay Acute-Care Hospitals for Outpatient Services They Provide to Beneficiaries in a Covered Part A Inpatient Stay at Other Facilities (PDF)”[7] MLN Matters article.

1 “Non-Physician Outpatient Services Provided Before or During Inpatient Stays: Bill Correctly,” Fast Facts, Medicare Learning Network, Centers for Medicare & Medicaid Services, December 21, 2020, http://go.cms.gov/3ivCwRe.
2 Amy J. Frontz, “Medicare Made $11.7 Million in Overpayments for Nonphysician Outpatient Services Provided Shortly Before or During Inpatient Stays,” Office of Inspector General, U.S. Department of Health & Human Services, May 2020, https://go.usa.gov/xvvkt.
3 “FAQs on the 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients,” MLN Matters SE20024, December 3, 2020, https://go.cms.gov/3sJ5UIA.
4 Centers for Medicare & Medicaid Services, “Chapter 6 - Hospital Services Covered Under Part B,” Medicare Benefit Policy Manual, Pub. 100-02, revised December 31, 2020, https://go.cms.gov/39U0HoJ.
5 Centers for Medicare & Medicaid Services, “Chapter 12 - Physicians/Nonphysician Practitioners,” Medicare Claims Processing Manual, Pub. 100-04, revised September 18, 2020, https://go.cms.gov/2XXxnb5.
6 Medicare Program; Payment Policies Under the Physician Fee Schedule, Five-Year Review of Work Relative Value Units, Clinical Laboratory Fee Schedule: Signature on Requisition, and Other Revisions to Part B for CY 2012 76 Fed. Reg. 73,026 (November 28, 2011), https://bit.ly/3o01RUn.
7 “Medicare Does Not Pay Acute-Care Hospitals for Outpatient Services They Provide to Beneficiaries in a Covered Part A Inpatient Stay at Other Facilities,” MLN Matters, SE17033 Revised, December 13, 2017, https://go.cms.gov/3p6MuLe.

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