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Submit an inpatient claim for an outpatient admitted to acute care

APCs Weekly Monitor, August 19, 2005

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Submit an inpatient claim for an outpatient admitted to acute care

QUESTION: If a patient requires admission on the same day following outpatient chemotherapy, should we bill for the chemotherapy services separately on an outpatient bill, or are all the services bundled into the inpatient bill?

ANSWER: According to the Medicare Claims Processing Manual, pub. 100-04, chapter 3, section 40.3:

Therapeutic outpatient services that are related to a patient's hospital admission and that are provided by the hospital, or by an entity wholly owned or operated by the hospital (or by another entity under arrangements with the hospital), to the patient during the three days immediately preceding the date of the patient's admission are deemed to be inpatient services and are included in the inpatient payment. This provision applies only when the patient has Part A coverage.

Therefore, when a patient has outpatient chemotherapy and is admitted to inpatient acute care the same day, submit an inpatient claim for all the services the patient received in the outpatient and inpatient setting. In this instance, Medicare's one- and three-day window provision applies. These guidelines are for the hospital setting.

The guidelines for payment for inpatient (and outpatient) services furnished by a critical access hospital (CAH) are different. These are also explained in the Medicare Claims Processing Manual, pub. 100-04, chapter 3, section 30.1.1 as follows:

Because CAHs are exempt from the 1- and 3-day window provisions, services rendered by a CAH to a beneficiary who is an outpatient prior to that beneficiary's admission to the CAH as an inpatient, are not bundled on the inpatient bill. Outpatient CAH services must be billed as such and on a separate bill (85x TOB) from inpatient services.

CWF and the shared system shall bypass the CAH provider numbers when applying the edits that compare hospital outpatient and inpatient bills to apply the window provisions. Outpatient services rendered on the date of admission to an inpatient setting are still billed and paid separately as outpatient services in a CAH.

Therefore, when a patient has outpatient chemotherapy in a CAH and is admitted to inpatient acute care the same day, submit both an outpatient and inpatient claim for services in each setting. In this instance, Medicare's one- and three-day window provision does not apply.

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