CMS has guidelines for what to do if certain services are denied under a Part A claim — some services may still be paid under a Part B claim, but all other rules must still be followed, especially including the rule for timely filing. Below are relevant chapters from the CMS Manuals.

List of Part B Services Covered for Inpatient

Medicare Benefit Policy Manual
Chapter 6 – Hospital Services Covered Under Part B
(PDF Format, 163KB, 28 pgs.)

Go to this Section (pg 3): 10 – Medical and Other Health Services Furnished to Inpatients of Participating Hospitals

Billing Outpatient Observation Services

Medicare Claims Processing Manual
Chapter 4 – Part B Hospital (Including Inpatient Hospital Part B and OPPS)
(PDF Format, 1.5MB, 205 pgs.)

Go to this Section (pg 179): 290 – Outpatient Observation Services

ALSO SEE:

Medicare Claims Processing Manual
Chapter 1 – Transmittal 1760, June 2009
(PDF Format, 932KB, 302 pgs.)

Go to pg 9 of the PDF document for “Clarification Related to Observation Services”


Other Resources:

Below are some other important considerations, answering questions we have received from clients.

Time Limitations for Filing (or Refiling) Claims

Medicare Claims Processing Manual
Chapter 1 – General Billing Requirements
(PDF Format, 932KB, 302 pgs.)

Go to this Section (pg 177): 70 -Time Limitations for Filing Provider Claims to Fiscal Intermediaries and Carriers

Reporting Hours for Observation Services

Medicare Claims Processing Manual
Chapter 4 – Part B Hospital (Including Inpatient Hospital Part B and OPPS)
(PDF Format, 1.5MB, 205 pgs.)

Go to this Section (pg 180): 290.2.2 – Reporting Hours of Observation

ALSO SEE:

Medicare Claims Processing Manual
Chapter 1 – Transmittal 1760, June 2009
(PDF Format, 932KB, 302 pgs.)

Go to pgs 26-27 of the PDF document for clarifying language added to “Reporting Hours of Observation”

Use of Condition Code 44

Medicare Claims Processing Manual
Chapter 1 – Transmittal 1760, June 2009
(PDF Format, 932KB, 302 pgs.)

Go to pgs. 14-16 of this PDF document for updates to Section 50.3 – When an Inpatient Admission May be changed to Outpatient Status

 

 

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