Health Information Management

Q/A: Procedures not on the inpatient-only list

APCs Insider, June 29, 2012

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Q:  We have payers who say if a procedure is not on Medicare’s Inpatient only list, it should never be done on an inpatient basis.  We don’t believe that this is Medicare’s intent, but haven’t been able to find any specific documentation that the payers will accept.  Are we missing something?

A:  CMS uses the inpatient-only list to define procedures that it believes should be performed on an inpatient basis for the Medicare population because of the:
  • Nature of the procedure
  • Need for at least 24 hours of postoperative care
  • Underlying physical condition of the patients most often having the particular procedure
CMS created the list to be a payment policy for services that it would not reimburse if performed as an outpatient. It was not meant to be an all-inclusive inpatient list meaning that no other procedures would warrant inpatient status. 
In the July OPPS update (Transmittal 2483), CMS notes that it is changing the language in the Medicare Claims Processing Manual (Pub. 100-04) to indicate“inpatient only guidelines are being clarified to state that procedures removed from the ‘inpatient only’ list may be appropriately furnished in both the inpatient and outpatient settings and such procedures continue to be payable when furnished in the inpatient setting.”
While CMS does not issue coverage requirements or payment requirements for non-Medicare payers, this documentation may assist you in discussions with your other payers.
Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.


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