Description
All diagnostic (including clinical diagnostic laboratory tests) services and related non-diagnostic services provided to a beneficiary by the admitting hospital within 3 days (for IPPS Hospitals) prior to or 1 day (NON IPPS Hospitals) prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment.
Affected Code(s)
Diagnostic codes are identified as any CPT/HCPCS code billed with a revenue code: 0254, 0255, 030X, 031X, 032X, 0341, 0343, 035X, 0371, 0372, 040X, 046X, 0471, 0481, 0489, 93451-3464, 93503, 93505, 93530-93533, 93561-93568, 93571-93572, G0275, G0278, 0482, 0483, 053X, 061X, 062X, 073X, 074X, 0918, 092X
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §40.3(B)- Outpatient Services Treated as Inpatient Services - Preadmission Diagnostic Services; §40.3(D) Outpatient Services Treated as Inpatient Services - Other Preadmission Services
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. American Medical Association (AMA) HCPCS and CPT Codebook