Revenue Cycle

CMS to resolve incorrect claims processing issue for 12X and 13X bill types

Recovery Auditor Report, April 5, 2012

On February 24, CMS sent out an update informing providers that it has identified a Medicare claims processing issue that has been causing hospital outpatient services rendered in an institutional setting to be processed incorrectly. Specifically, the notice provided guidance on claims inappropriately overlapping when billed with a 12X or 13X type of bill with the same date of service.

CMS had previously issued guidance in Transmittal R2386CP, which clarified that providers could separately bill outpatient services rendered prior to a non-covered inpatient admission. It also states that the dividing line for services billed on the inpatient and outpatient claims is the inpatient order, and that services “prior to the point of admission” are to be billed as outpatient services with a 13X bill type. This includes services in the outpatient and emergency departments.

But many providers continued to see denied inpatient cases involving 13X bill types, according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc.

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