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Note from Hugh

Medicare Weekly Update, October 2, 2007

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Those of you who happened to listen to CMS' Hospital Open Door Forum conference call last week will recall CMS commenting that Medicare does not permit "retroactive" inpatient admissions. You may also recall that, in response to CMS's comments, I asked CMS (on the call) to clarify whether CMS has changed its policy on situations in which a patient presents under emergency circumstances, and an "inpatient only" procedure is performed prior to the patient being admitted as an inpatient.

This issue relates back to Program Memo A-02-129 issued by CMS in January 2003. In that Program Memo, CMS provided a "Summary of Billing and Payment Rules When a Procedure Designated as an Inpatient Procedure (by OPPS status indicator C) Is Performed On a Patient Whose Status Is Outpatient."  That summary states the following:

1. If a procedure designated as an inpatient procedure must be performed on a patient whose status is that of an outpatient, the hospital may:

a. Admit the patient and submit an inpatient claim for payment under the inpatient PPS, or

b.  Admit and transfer the patient to another provider and submit a claim for a per diem DRG rate.

This summary seems to say that if a hospital must perform an "inpatient only" procedure on an outpatient, the hospital may admit the patient (presumably immediately after the surgery) and bill the procedure as an inpatient service notwithstanding the fact that the patient was an outpatient at the time the procedure was performed.

Unfortunately, CMS was not able to provide the clarification I requested on the call.  However, I have submitted a follow-up email to Natalie Highsmith at CMS requesting clarification as to whether Program Memo A-02-129 still reflects CMS' current policy with regard to emergency "inpatient only" procedures, or whether that policy is superseded by CMS comments on last week's Hospital Open Door Forum call.

I will report on CMS' response in a future issue of Hugh Aaron's Medicare Weekly Update once I receive a response to my email.

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