Outpatient to Inpatient Status Change

When a patient is treated as an outpatient prior to admission as an inpatient in the same facility, the provisions for billing the outpatient services depend on the type of facility and the types of services provided.

Critical Access Hospitals

Critical Access Hospitals (CAHs) are paid based on cost, and are not subject to the preadmission bundling provisions applied to hospitals paid under the Prospective Payment System.

All outpatient services provided up to the time of a physician order for admission are to be billed as outpatient services separate from the inpatient claim, even if the inpatient admission order is made during the same encounter.

Example: Patient A presented to the emergency department at 9 p.m. on June 15. Upon examination, the emergency room physician determined that diagnostic studies were needed and the patient needed to be monitored for a period of time before a decision about inpatient admission could be made. At 11:30 p.m., the physician referred the patient to observation.

At 10:30 a.m., the physician determined that the patient's condition and the length of time anticipated for recovery warranted inpatient admission, and wrote an order for admission.

The patient was discharged on June 20.

Outpatient claim
  • Type of bill 851, dates of service 6/15/13 – 6/16/13
  • Rev code 762, 11 units, line item date of service 6/15/13
Inpatient claim
  • Type of bill 111, dates of service 6/16/13-6/20/113

 

Prospective Payment System (PPS) Hospitals

Hospitals paid under the Inpatient Prospective Payment System (IPPS) must include all outpatient diagnostic and admission-related non-diagnostic services provided up to three calendar days preceding the date of admission as an inpatient. All services other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital), provided during the 3-day bundling window are deemed related to the admission and are not separately billable, unless the hospital attests otherwise.  

Condition code 51, "Attestation of Unrelated Outpatient Non-diagnostic Services" is used to indicate the non-diagnostic services are clinically distinct or independent from the reason for the beneficiary's admission in order to bill them separate from the inpatient claim.

Inpatient Rehabilitation Facilities, Inpatient Psychiatric Facilities, Long Term Care Hospitals

Hospitals excluded from IPPS are subject to bundling diagnostic and admission related non-diagnostic services as discussed above when those services are provided the day of, and/or the day before, the inpatient admission.

Condition code 51, "Attestation of Unrelated Outpatient Non-diagnostic Services" is used to indicate the non-diagnostic services are clinically distinct or independent from the reason for the beneficiary's admission in order to bill them separate from the inpatient claim.

Resources

 

Last Updated Oct 18, 2018