CMS Pub. 100-04, ch. 4, § 10.12

Services

(Rev. 3238, Issued: 04-22-15, Effective: 04-01-15 Implementation: 04-06-15)

The policy for the payment window for outpatient services treated as inpatient services is

discussed in chapter 3 § 40.3 of this manual. The policy requires payment for certain

outpatient services provided to a beneficiary on the date of an inpatient admission or

during the 3 calendar days (or 1 calendar day for a non-IPPS hospital) prior to the date of

an inpatient admission to be bundled (i.e., included) with the Medicare Part A payment

for the beneficiary’s inpatient admission if those outpatient services are provided by the

admitting hospital or an entity that is wholly owned or wholly operated by the admitting

hospital. The policy applies to all diagnostic outpatient services (including non-patient

laboratory tests) and non-diagnostic services (i.e., therapeutic) that are related to the

inpatient stay. Ambulance and maintenance renal dialysis services are not subject to the

payment window.

All diagnostic services (including non-patient laboratory tests) provided to a Medicare

beneficiary by a hospital (or an entity wholly owned or wholly operated by the hospital)

on the date of the beneficiary’s inpatient admission or during the 3 calendar days (or, in

the case of a non-subsection (d) hospital, 1 calendar day) immediately preceding the date

of admission are required to be included on the Part A bill for the inpatient stay.

Outpatient non-diagnostic services that are related to an inpatient admission must be

bundled with the Part A billing for the inpatient stay. An outpatient service is related to

the admission if it is clinically associated with the reason for a patient’s inpatient

admission. In accordance with section 102 of Pub. L. 111-192, for services furnished on

or after June 25, 2010, all outpatient non-diagnostic services, other than ambulance and

maintenance renal dialysis services, provided by the hospital (or an entity wholly owned

or wholly operated by the hospital) on the date of a beneficiary’s inpatient admission are

deemed related to the admission, and thus, must be billed to Part A with the inpatient

stay. Also, outpatient non-diagnostic services, other than ambulance and maintenance

renal dialysis services, provided by the hospital (or an entity wholly owned or wholly

operated by the hospital) on the first, second, and third calendar days for a subsection (d)

hospital paid under the IPPS (first calendar day for non-subsection (d) hospitals)

preceding the date of a beneficiary’s inpatient admission are deemed related to the

admission, and thus, must be billed to Part A with the inpatient stay, unless the hospital

attests to specific non-diagnostic services as being unrelated to the hospital claim (that is,

the preadmission non-diagnostic services are clinically distinct or independent from the

reason for the beneficiary‘s admission). Outpatient non-diagnostic services provided

during the payment window that are unrelated to the admission, and are covered by Part

B, may be separately billed to Part B. The June 25, 2010 effective date of section 102 of

Pub. L. 111-192 applies to outpatient services provided on or after June 25, 2010.

In the event that there is no Part A coverage for the inpatient stay, the hospital may bill

Part B for the services provided to the beneficiary prior to the point of inpatient

admission (i.e., the time of formal admission pursuant to the inpatient admission order)

that would otherwise be included in the payment window for Part A payment, including

services requiring an outpatient status. Certain Part B inpatient services provided to the

beneficiary after the point of inpatient admission (i.e., the time of formal admission

pursuant to the inpatient admission order) may also be billed to Part B when Part A

payment cannot be made. See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6,

§10 “Medical and Other Health Services Furnished to Inpatients of Participating

Hospital" for a full description of this policy.

A hospital may attest to specific non-diagnostic services as being unrelated to the hospital

Part A claim (that is, the preadmission non-diagnostic services are clinically distinct or

independent from the reason for the beneficiary‘s admission) by adding a condition code

51 (definition “51 - Attestation of Unrelated Outpatient Non-diagnostic Services”) to the

separately billed outpatient non-diagnostic services claim. Providers may submit

outpatient claims with condition code 51 starting April 1, 2011, for outpatient claims that

have a date of service on or after June 25, 2010. Outpatient claims with a date of service

on or after June 25, 2010, that did not contain condition code 51 received prior to April 1,

2011, will need to be adjusted by the provider if they were rejected by FISS or CWF.