Health Information Management

Know what inpatient services are eligible for reimbursement under the OPPS

HIM-HIPAA Insider, February 24, 2009

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Effective January 1, coders can report HCPCS code C9899 when providers implant a prosthetic device for a Medicare beneficiary who is an inpatient but who doesn’t have Part A coverage of inpatient services on the date of the procedure. This concept—receiving reimbursement for an inpatient service under the outpatient prospective payment system (OPPS)—isn’t new. In fact, there are 11 categories of inpatient Part B services that providers can bill under the OPPS. However, the recent guidance from CMS about HCPCS code C9899 offers a good reminder of financial opportunities that your hospital might be missing.

Medicare will pay for 11 categories of inpatient Part B procedures under the OPPS:

  • Diagnostic x-ray tests and other diagnostic tests (excluding clinical diagnostic laboratory tests)
  • X-ray, radium, and radioactive isotope therapy, including materials and services of technicians
  • Surgical dressings applied during an encounter at the hospital, as well as splints, casts, and other devices used for reduction of fractures and dislocations
  • Implantable prosthetic devices
  • Hepatitis B vaccine and its administration, as well as certain preventive screening services such as pelvic exams, screening sigmoidoscopies, and screening colonoscopies
  • Bone mass measurements
  • Prostate screening
  • Immunosuppressive drugs
  • Oral anticancer drugs
  • Oral drugs prescribed for use as acute antiemetics and used as part of an anticancer chemotherapeutic regimen
  • Epoetin Alfa, an injectable drug used to treat anemia

Medicare will reimburse providers for the eligible items or procedures when one of the four criteria is met:

  • The patient has exhausted his or her Part A coverage
  • The inpatient stay is deemed unreasonable and unnecessary
  • The patient is not eligible for Part A coverage
  • The service is never covered under Part A coverage

Editor’s note: For more information about how to receive payment for these services, visit the HCPro Web site. This article was adapted from the February issue of Briefings on Coding Compliance Strategies.

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