Health Information Management

MLN Matters addresses changes to IPPS patient status payments

HIM-HIPAA Insider, November 17, 2014

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CMS released MLN Matters® MM8959 to clarify changes to the Medicare Claims Processing Manual for patient status payment policies originally implemented in the 2014 IPPS final rule. The MLN Matters guidance corresponds with revisions outlined in CMS’ Change Request 8959.
Under the 2014 IPPS final rule, if an inpatient admission is not reasonable or necessary, CMS will allow hospitals to bill for services that would have been reasonable and necessary for outpatient treatment. Hospitals must bill for the reasonable and necessary outpatient services before the timeframe for submitting claims expires. However, this excludes billing for services that require outpatient status, including outpatient visits, ED visits, and observation services.
Changes outlined by CMS and in the MLN Matters article affect Chapter 240 of the Medicare Claims Processing Manual, which details circumstances when Medicare will pay for Part B inpatient services. The revision clarifies billing for nursing services that are often considered to be part of room and board charges associated with an inpatient admission. Typically, hospitals do not separately charge for these services under Medicare Part A. However, the revision states that some services provided by floor nurses (e.g., IV infusions and injections, blood administration, nebulizer treatments) may or may not have a separate charge depending on whether the service is classified as routine or ancillary by providers of the same class in the same state.
Some providers established a customary practice resulting in separate charges for these nursing services based on the Provider Reimbursement Manual (PRM–1) instructions. To be recognized, this practice must be consistent for all patients and must not result in result in an inequitable apportionment of cost to the program. Providers must follow the PRM–1 instructions if billing for these services as separate charges. The charges and documentation must adhere to HCPCS definitions for the services to be separately billable.
CMS issued this revision November 6, 2014. It is effective October 1, 2013, and will be implemented February 10, 2015. 
To learn more about charging for ancillary bedside services, join HCPro and experts Denise Williams, RN, CPC-H, and Valerie A. Rinkle, MPA, at 1 p.m. (Eastern) Thursday, November 20 for the live webcast Ancillary Bedside Procedures: When to Charge Beyond Hourly Observation and the Room Rate.


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