1 Day Payment Window - JE Part A

When a beneficiary, with Part A coverage, receives outpatient hospital services the day immediately preceding his/her hospital admission, the outpatient hospital services are treated as inpatient services. This provision applies when the beneficiary is admitted to the hospital before midnight of the day following receipt of outpatient services. The day he/she is formally admitted as an inpatient is counted as the first inpatient day. Services are included in the applicable Prospective Payment System (PPS) payment and cannot be billed separately.

Non-subsection (d) Hospitals and Units Excluded from Inpatient PPS (IPPS)

• Non-subsection (d) hospitals are: psychiatric hospitals and units; Inpatient Rehabilitation Facilities (IRFs) and units; long-term care hospitals (LTCHs); children's hospitals; cancer hospitals; and the U.S. unincorporated territories' hospitals of American Samoa, Guam and the Northern Mariana Islands (Section 1886 (d)(1)(B) of the Social Security Act defines "non-subsection (d) hospitals")
• Payment window applies only to services furnished within one day prior to and on beneficiary admission date
• Tax Equity and Fiscal Responsibility Act (TEFRA)-reimbursed facilities (including the above mentioned unincorporated island territories) are subject to 1-day payment window per guidance offered to other non-subsection (d) hospitals

Critical Access Hospitals (CAHs)

• Not typically subject to 1-day (nor 3-day) payment window
• If beneficiary receives outpatient services at a CAH, that is either wholly owned or operated by a non-CAH hospital, and is admitted as inpatient to a non-CAH hospital, on same day or within one day immediately following outpatient services, services are subject to 1-day payment window provisions

Outpatient Non-Diagnostic Services (other than ambulance and maintenance renal dialysis services)

• Services provided by hospital (or entity wholly owned or wholly operated by hospital) on beneficiary's admission date, or within one day of it, are deemed related to admission and must be billed with inpatient stay
• Hospitals must attest when specific non-diagnostic services are unrelated to hospital claim (that is, preadmission non-diagnostic services are clinically distinct or independent from reason for 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

Diagnostic Services (including clinical diagnostic laboratory tests)

• If there is Part A coverage, these are deemed inpatient services and are included in inpatient payment when admitting hospital, or entity wholly owned or wholly operated by admitting hospital (or another entity under arrangements with admitting hospital), provides them to a beneficiary within one day prior to and/or on his/her admission date
• Common Working File (CWF) rejects such services when a line item date of service (LIDOS) falls on admission date, or within three days prior to admission, for hospitals excluded from IPPS, when there is an admission to an IPPS hospital

Diagnostic Revenue Codes

Resource

• CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.3B, 40.3C