Health Information Management

CMS guidance on Part B rebilling creates more provider confusion

APCs Insider, May 2, 2014

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 by Steven Andrews

CMS' 2-midnight policy, which directs the agency's auditors to assume hospital admissions with proper documentation are reasonable and necessary when the patient stays in the hospital spanning two midnights, has been the subject of controversy, repeatedly delayed enforcement, and a lawsuit.
Attempts by CMS to further clarify how to implement payment policies from its 2014 IPPS Final Rule have only led to more confusion and administrative burden for hospitals, with Transmittal 2877 providing seemingly contradictory advice on rebilling for certain outpatient services.
In Section 240.5 of the transmittal, CMS covers payments for Part B services in the outpatient payment window for patients who were treated as inpatients but a Part A payment cannot be made, because they did not qualify as inpatients.
CMS writes that services requiring outpatient status that are only provided in an outpatient setting—such as clinic visits, ED visits, and observation services— are not payable inpatient Part B services. This makes sense, as all of these services always require outpatient status.
CMS adds that routine inpatient services are considered those generally included by providers in a daily service (room and board) charge—including:

…the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made to Medicare Part A.

These services are never outpatient services, and therefore are not separately billable Inpatient Part B ancillary services. They include routine nursing services that are captured in the Room and Board rate (such as IV infusions and injections, blood administration, and nebulizer treatments), which are not separately billable Inpatient Part B ancillary services.

CMS’ example of services such as injection and infusions and blood administration being routine nursing services, and therefore never outpatient services, is very confusing and contradictory to previous guidance provided by the agency. It specifically stated these services could be carved out of the room and board rate and billed on a separate line on an inpatient claim, according to Jugna Shah, MPH, president and founder of Nimitt Consulting.
"Providers who have split these charges out on their inpatient claims have also pulled the dollars out of their room and board charge so that they are not 'double dipping,' so to speak," says Shah. "Hospitals that have been breaking out these types of charges should have the opportunity to bill for them under inpatient Part B billing, and receive separate payment, since these are most certainly outpatient services." 
Perhaps CMS intends for this, but the language from the transmittal is confusing to providers, Shah adds. It also leaves open the question of what providers who have not carved these services out of their room and board rate are allowed to bill on their Part B 12x claims.
The guidance appears to be telling providers they cannot rebill for certain outpatient type services if an inpatient claim does not meet the 2-midnight criteria and a Part B 12x claim is required, yet this does not seem to be consistent with the spirit of the rebilling guidance.
Has your billing office filed any inpatient Part B 12x claims following the instructions in Transmittal 2877 related to billing outpatient services when an inpatient claim has been denied or doesn’t meet medical necessity? If so, click here and scroll to the bottom of the page to vote in the following poll:
Have you carved out discrete nursing procedures, described by CPT® codes (e.g., infusions and injections, blood administration, and nebulizer treatments), from your room and board rates?
  • Yes, we’ve carved them out and are dropping CPT codes and charges on Part B 12x claims and are receiving APC/OPPS payment.
  • No, we have not carved them out, so we remove the room rate and add applicable charges and CPT codes for various discrete nursing procedures (e.g., infusions and injections) to our Part B 12x claims and are receiving APC/OPPS payment.
  • No, we have not carved discrete nursing procedures out of our room rate and we are not dropping charges for these types of procedures. We submit a no-pay Part B 12x claim for which we receive no separate APC/OPPS payment.


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