In Context

October 29, 2013

Drill Down – Pre-Admission Services

RAC Region A contractor Performant posted an automated review on October 17, 2013 for the states of Delaware, Maryland, New Jersey, Pennsylvania and District of Columbia, regarding pre-admission services for Outpatient Hospital providers. Per the contractor’s description of this audit issue, diagnostic and non-diagnostic services provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital, within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment.

One of the references listed for this issue is the CMS 100-04 Medicare Claims Processing Manual, Chapter 3, Section 40.3:

A. Outpatient Services Followed by Admission Before Midnight of the Following Day (Effective For Services Furnished Before October 1, 1991)

When a beneficiary receives outpatient hospital services during the day immediately preceding the hospital admission, the outpatient hospital services are treated as inpatient services if the beneficiary has Part A coverage. Hospitals and FIs apply this provision only when the beneficiary is admitted to the hospital before midnight of the day following receipt of outpatient services. The day on which the patient is formally admitted as an inpatient is counted as the first inpatient day.

When this provision applies, services are included in the applicable PPS payment and not billed separately. When this provision applies to hospitals and units excluded from the hospital PPS, services are shown on the bill and included in the Part A payment. See Chapter 1 for FI requirements for detecting duplicate claims in such cases.

B. Preadmission Diagnostic Services (Effective for Services Furnished On or After January 1, 1991)

Diagnostic services (including clinical diagnostic laboratory tests) provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment, unless there is no Part A coverage. For example, if a patient is admitted on a Wednesday, outpatient services provided by the hospital on Sunday, Monday, Tuesday, or Wednesday are included in the inpatient Part A payment.

For this provision, diagnostic services are defined by the presence on the bill of the following revenue and/or CPT codes:

 

0254 -	Drugs incident to other diagnostic services
0255 -	Drugs incident to radiology
030X -	Laboratory
031X -	Laboratory pathological
032X -	Radiology diagnostic
0341, 0343 -	Nuclear medicine, diagnostic/Diagnostic Radiopharmaceuticals
035X -	CT scan
0371 -	Anesthesia incident to Radiology
0372 -	Anesthesia incident to other diagnostic services
040X -	Other imaging services
046X -	Pulmonary function
0471 -	Audiology diagnostic
0481, 0489-	Cardiology, Cardiac Catheter Lab/Other Cardiology with CPT codes 93451-93464, 93503, 93505, 93530-93533, 93561-93568, 93571-93572, G0275, and G0278 diagnostic
0482-	Cardiology, Stress Test
0483-	Cardiology, Echocardiology
053X -	Osteopathic services
061X -	MRT
062X -	Medical/surgical supplies, incident to radiology or other diagnostic services
073X -	EKG/ECG
074X -	EEG
0918-	Testing- Behavioral Health
092X -	Other diagnostic services

 

This automated issue will be looking at outpatient hospital claim data and the beneficiary’s claim history for any inpatient admissions and their corresponding date of service that is included in Part A payments.

RAC issues for the week of October 28 – November 1, 2013:

RAC Region A Performant

Physician/Non-Physician Practitioner

·         Annual Wellness Visit (AWV) – JL - Annual Wellness Visit (AWV) G0438 (initial visit) billed more than once in a lifetime.

·         Evaluation and Management Per Diem Codes, Excess Units – JL - Initial hospital care and subsequent hospital care codes are "per diem" services and may be reported only once per day by the same physician.

Outpatient Hospital

·         Pre-admission Services – JL - Diagnostic and non-diagnostic services provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital, within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment.