Revenue Cycle

Tip: Billing for PET scans during an unrelated inpatient stay

Medicare Update for CAHs, October 5, 2011

A patient is admitted to the hospital for care of a heart attack and the patient’s oncologist schedules a PET scan related to the patient’s recent diagnosis of breast cancer. The scan was schedule for the patient’s convenience while still an inpatient and required continued inpatient     care for their cardiac condition. The PET scan, however, did not meet the Medicare conditions of coverage for staging of breast cancer and under the applicable policy, was not considered medically necessary for treatment of the breast cancer.

In this particular scenario, the only circumstance for which the hospital may bill the patient for the PET scan is if they provided a provided a proper HINN 11 notice to the patient prior to the service being performed. A non-covered diagnostic service, which is not bundled into or integral to the reason/diagnosis for the inpatient stay, is separately billable to the patient.

<Medicare Claims Processing Manual, Transmittal 982, Section II “Use of HINN 11” >

This tip was adapted from HCPro’s Medicare Boot Camp® - Critical Access Hospital Version.

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