- Outpatient Services for Registered Inpatients
- Using the IVR to Avoid Eligibility and Entitlement-Related Claim Rejections and RTPs
- Allergen Immunotherapy Preparation (95144-95165)
- Ambulatory Surgical Center Approved HCPCS Codes and Payment Rates
- Annual Wellness Visits ‑ Billing Tips for Physicians
- Billing for FQHC MAO Plan Supplemental Payment (PPS Providers)
- Billing for Services Not Included in the FQHC Benefit
- Attention all OPPS Providers: Provider-Based Department Edits Being Implemented on/after 8/1/2023
- Billing Medicare for a Denial - Condition Code 21
- URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations
- Billing Medicare Part A When VA-Eligible Medicare Beneficiaries Receive Services in Non VA Facilities
- Condition Code G0 Reminder
- CPT Code 15830: Excision, Excess Skin and Subcutaneous Tissue; Abdomen, Infraumbilical Panniculectomy
- Electronically Submitted Claims that Exceed $99,999.99
- ESRD Facilities: Clarification for Providing Dialysis Services to Patients Acute Kidney Injury
- Federally Qualified Health Centers Behavioral Health Claims Job Aid
- Federally Qualified Health Centers Contracting with Medicare Advantage Plans
- Fee-For-Time Compensation Arrangement and Reciprocal Billing Job Aid
- Answers to Common Fee-for-Time Compensation Arrangements Questions
- FQHC and Group Therapy Services Job Aid
- Hospital Acquired Conditions and Present on Admission Resource for Acute Care Hospital Facilities
- Long-Term Care Hospitals: How to Request Adjustments of Claims Paid at the Site Neutral Rate
- Inhalation Treatment CPT 94640 – Billing Errors
- Immunization Roster Billing
- JK: Medicare Paid Hospital Providers Twice for Nonphysician Outpatient Services Provided Shortly Before or During Inpatient IPPS Hospital Stays
- Nonphysician Practitioners Billing for Surgical Procedures
- Professional Services During a Patient Hospice Election
- Professional Services During a Patient Hospice Election
- Proper Billing for Finger and Toe Procedures
- Proper Submission of Fee-For-Time Compensation Arrangements and Reciprocal Billing Arrangements
- Proper Use of Taxonomy Codes
- A/B Rebilling Facts
- Common Reciprocal Billing Questions and Answers
- Reminder for Avoiding Claim Denials for Positron Emission Tomography Scans
- Reminder on Deleting Revenue Code Line(s) in the Fiscal Intermediary Standard System Direct Data Entry System
- Repetitive Outpatient Services for Providers Submitting Institutional Outpatient Claims
- Reporting Multiple Qualifying Visits on the Same Date of Service for FQHC Reimbursement
- Unlisted and Not Otherwise Classified Procedure Codes
- What All Facilities Need to Know About the Long-Term Care Hospital Three-Day or Less Interrupted Stay Policy
- Fiscal Year/Calendar Year Claim Split
- Hospitals Must Correctly Assign Severe Malnutrition Diagnosis Codes to Inpatient Claims
Outpatient Services for Registered Inpatients
There are occasional circumstances in which a registered inpatient may require a service that is not available at the inpatient facility. These inpatient facilities include acute-care hospitals (POS 21), skilled nursing facilities (POS 31), psychiatric inpatient facilities (POS 51) and comprehensive inpatient rehabilitation facilities (POS 61) as well as other types of hospitals represented by place of service (POS) code 21 unless there is a more specific POS code. Such outpatient services are performed on a same-day basis; the patient is transported to another facility or physician’s office and returned to the original facility on the same date of service.
When such services occur, the following rules apply:
For Part A services (nonphysician outpatient services) performed outside of the facility at which the patient is a registered inpatient:
- The facility which provides a Part A service must seek compensation from the original facility at which the patient is a registered inpatient. That original facility is responsible for the cost of the service(s) performed at the outside facility and will make payment from Medicare’s reimbursement for the inpatient stay.
- The original facility includes the nonphysician outpatient services on its inpatient claim. This is commonly referred to as under arrangement billing.
- Examples of services that may be performed under these circumstances (generally referred to as “under arrangement”) include outpatient dialysis, radiation therapy, and diagnostic procedures such as MRI.
For Part B services at a physician’s office, performed outside of the facility at which the patient is a registered inpatient:
- The physician’s office service must be billed with the POS code that reflects the inpatient facility at which the patient is a registered inpatient (i.e., POS codes 21, 31, 51 or 61 as described above).
- The physician’s office service must be coded using a CPT code correlative to the POS code used on the claim. For example, an office service for a new patient would be represented by an inpatient CPT code in the range of 99221‒99223, while an office service for an established patient would be represented by an inpatient CPT code in the range of 99231‒99233.
- The important factor here is that the POS code must correlate to the CPT code. Claim editing is set to allow a subset of CPT codes per POS and claims will deny when this correlation is not established on the claims. Such denials, of course, are subject to appeal.
Related Content
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 10.4
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.5
- MLN Matters® Article: SE17033 Revised: Medicare Does Not Pay Acute-Care Hospitals for Outpatient Services They Provide to Beneficiaries in a Covered Part A Inpatient Stay at Other Facilities
Revised 11/3/2023