Medicare inpatient only services
The medicare hospital-only list refers to CPT and services that CMS usually only paid in the hospital environment and thus does not pay for under OPPS. Most of the hospital-only CPTs are operating processes that can be complicated, difficult and/or involve hospital care and co-ordinated care. Surgeons must be conscious of the processes listed because of the potential effect on reimbursement and hospital interactions.
“Inpatient only” services are generally, but not always, surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged.
No payment is made for an “inpatient-only” procedure submitted on the outpatient hospital type of bill, 13X. No payment is made for other services rendered on the same day as the “inpatient only” procedure.
An example of an “inpatient only” service is CPT code 33513, “Coronary artery bypass, vein only; four coronary venous grafts.”
Changes to the Inpatient-Only List (IPO) for CY 2019
The Medicare Inpatient-Only (IPO) list includes procedures that are typically only provided in the inpatient setting and therefore are not paid under the OPPS. For CY 2019, CMS is removing four procedures from the IPO list. CMS is also adding one procedure to the IPO list.
Example changes in the list during 2019
2019 Bariatric Surgery: Is the Surgery Medicare Inpatient Only or not?
43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) 43659 Unlisted laparoscopy procedure, stomach
43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption
43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy)
43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than verticalbanded gastroplasty
43845 Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch)
43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy
43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorptio
43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure)
Inpatient-only procedure performed in outpatient setting within payment window
If an “inpatient-only” procedure is performed in the outpatient setting, and the patient is subsequently admitted as an inpatient, the “inpatient-only procedure” can be reported on the inpatient claim when the services are:
* Provided on the date of inpatient admission
* Provided within 3 days of inpatient admission
* Deemed related to inpatient admission per the payment window policy
Inpatient-only Services
CMS to define the services for which payment under the OPPS is appropriate and the Secretary has determined that the services designated to be “inpatient only” services are not appropriate to be furnished in a hospital outpatient department. “Inpatient only” services are generally, but not always, surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. An example of an “inpatient only” service is CPT code 33513, “Coronary artery bypass, vein only; four coronary venous grafts.”
The designation of services to be “inpatient-only” is open to public comment each year as part of the annual rulemaking process. Procedures removed from the “inpatient only” list may be appropriately furnished in either the inpatient or outpatient settings and such procedures continue to be payable when furnished in the inpatient setting.
There is no payment under the OPPS for services that CMS designates to be “inpatient-only” services. These services have an OPPS status indicator of “C” in the OPPS Addendum B and are listed together in Addendum E of each year’s OPPS/ASC final rule. For the most current Addendum B and for Addendum E published with the OPPS notices and regulations, see http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html. Excluding the handful of exceptions discussed below, CMS does not pay for an “inpatient-only” service furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient hospital bill type (TOB 13X). CMS also does not pay for all other services on the same day as the “inpatient only” procedure.
There are two exceptions to the policy of not paying for outpatient services furnished on the same day with an “inpatient-only” service that would be paid under the OPPS if the inpatient service had not been furnished:
Exception 1: If the “inpatient-only” service is defined in CPT to be a “separate procedure” and the other services billed with the “inpatient-only” service contain a procedure that can be paid under the OPPS and that has an OPPS SI=T on the same date as the “inpatient-only” procedure or OPPS SI = J1 on the same claim as the “inpatient-only” procedure, then the “inpatient-only” service is denied but CMS makes payment for the separate procedure and any remaining payable OPPS services. The list of “separate procedures” is available with the Integrated Outpatient Code Editor (I/OCE) documentation. See http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/.
Exception 2: If an “inpatient-only” service is furnished but the patient expires before inpatient admission or transfer to another hospital and the hospital reports the “inpatient only” service with modifier “CA”, then CMS makes a single payment for all services reported on the claim, including the “inpatient only” procedure, through one unit of APC 5881, (Ancillary outpatient services when the patient dies.) Hospitals should report modifier CA on only one procedure