Part A to B Rebilling Guidance - JE Part A
Part A to B Rebilling Guidance
When an inpatient admission is found to be not reasonable and necessary, payment is allowed for all hospital services furnished that would have been reasonable and necessary in an outpatient setting.
Hospitals may also be paid for Part B inpatient services if it's determined that a beneficiary should have received hospital outpatient services rather than inpatient services, and the patient has already been discharged from the hospital.
Note: Claims that are not affected by this billing are; Recovery Audit Contractor (RAC) pre-payment review claims, Supplemental Medical Review Contractor (SMRC) post-payment review claims denied for Intensive Inpatient Rehabilitation Therapy, and pre-payment denials based on contractor review for Bariatric Surgery.
Self-audit Claims
Submit a Part A provider liable claim with the below information on the UB-04 claim form.
- Type of Bill (TOB) 110
- Non-covered days
- From and thru dates of service
- Appropriate patient status
- Occurrence Span Code M1 with dates of service
- Non-covered charges
- Diagnosis codes
- Procedure codes
After the inpatient claim has finalized, an inpatient Part B ancillary claim (TOB 12x) can be submitted.
Inpatient Part B Hospital Services
Includes services that are not strictly provided in an outpatient setting. Medicare pays for certain non-physician medical services.
Non-covered Services at Revenue Code Level
A list of non-covered revenue codes can be viewed under CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 240.1.
For admissions denied as not reasonable and necessary, submit a Part B inpatient ancillary claim (TOB 12x) containing:
- Treatment authorization code: A/B Rebilling
- Condition code W2
- Original denied Document Control Number (DCN) in remarks
- For Direct Data Entry (DDE) or paper claims, enter word "ABREBILL" and denied inpatient DCN in remarks field. Example: ABREBILL12345678901234
Outpatient Services Provided Prior to Admission
Includes outpatient diagnostic services furnished to patients three days prior and up to the date of admission.
Covered Diagnostic Revenue Codes
| Revenue Code | Description |
|---|---|
| 0254 | Drugs incident to other diagnostic services |
| 0255 | Drugs incident to radiology |
| 030x | Laboratory |
| 031x | Laboratory pathological |
| 0341, 0343 | Nuclear medicine, diagnostic/Diagnostic Radiopharmaceuticals |
| 035x | CT scan |
| 0371 | Anesthesia incident to Radiology |
| 0372 | Anesthesia incident to other diagnostic services |
| 040x | Other imaging services |
| 046x | Pulmonary function |
| 0471 | Audiology diagnostic |
| 0481, 0489 | Cardiology |
| 0482 | Cardiology, Stress test |
| 0483 | Cardiology, Echocardiology |
| 053x | Osteopathic services |
| 061x | MRT |
| 062x | Medical/surgical supplies, incident to radiology or other diagnostic services |
| 073x | EKG/ECG |
| 074x | EEG |
| 0918 | Testing, Behavioral Health |
| 092x | Other diagnostic services |
Submit an outpatient Part B claim containing the below information on the UB-04 claim form.
- Type of Bill (TOB) 13x
- Applicable revenue codes/services
Resources
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 240.1 - Editing Of Hospital Part B Inpatient Services: Reasonable and Necessary Part A Hospital Inpatient Denials
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 3, Section 40.3
- CMS Medicare Learning Network (MLN) Matters (MM) 11181
- CMS MM 11413
