Health Information Management

Tip of the week: Unravel the costly inpatient-only procedures puzzle with these prevention practices

APCs Insider, August 1, 2008

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Best prevention practices for outpatient facilities dealing with inpatient-only procedures and denials include getting physicians on board and applying layers of safeguards from the operating room to the billing department. Facilities should comb every Outpatient Code Editor transmittal and pay special attention to the annual Addendum E, the most recent inpatient-only list in Excel format.

If an inpatient-only procedure gets through to the claim, a hospital can choose one of two options:
  • Take the loss because of the time and expense of appealing a denial. This is a safe, widely followed path and can be cost-effective for smaller hospitals. Ironically, it may not be the one CMS intended or anticipated

  • File the claim as fully noncovered. There is guidance supporting this step. Your information can alter the CMS database and lead to CMS removing procedures from the list. If you file the claim as fully noncovered, it is also possible that the procedure may be on the separate-procedures list and that same-day expenses apart from the procedure may be reimbursable.
 (This tip was adapted from Briefings on APCs. To view the entire tip, click here.)



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