Knowledge Base Article

On March 13, 2013, CMS released a Ruling and a Proposed Rule that changes Medicare’s existing policy and allows payment of all Part B hospital services that were furnished and would have been reasonable and necessary if the patient had been treated as an outpatient, rather than admitted as an inpatient, except for those services specifically requiring an outpatient status. CMS also released Change Request 8185 with billing instructions for Part B rebilling to be implemented July 1, 2013 and discussed the Part B rebilling rules on the April 2 Hospital Open Door Forum call. But even with all this information, there are parts of the new rules that remain somewhat confusing. We thought we would address some questions to hopefully clear some of the confusion. Note that more information is expected from CMS soon and we will do our best to keep you up to date.

What services go on the Part B outpatient claim (13x type of bill) and what services go on the Part B inpatient claim (12x type of bill)?

Outpatient services that were bundled into the Part A inpatient claim under the 3-day payment window rule can be separately billed on an outpatient claim (13x TOB) if the inpatient admission is determined to be not reasonable and necessary. Therefore services that were provided before the inpatient order was written would be on the 13x claim.

Part B services that were provided after the patient was admitted (after the admission order was written) would be eligible to be billed on the Part B inpatient claim (TOB 12x). Services that require an outpatient status, such as ER services and observation services, would not be provided after the inpatient admission order was written, so these types of services are not allowed on the 12x claim.

When can claims for Part B rebilling be submitted?

The Ruling was effective March 13, 2013 but Medicare has to work out the details of claims submission and allow the processing contractors time to put changes in place to accept the claims. Medicare published CR 8185 with billing instructions, but this CR will not be implemented until July 1, 2013. CMS has promised interim billing instructions to be released soon. Once these interim instructions are released, Part B rebilling claims can be submitted.The interim billing instructions are now available at http://www.cms.gov/Center/Provider-Type/Hospital/Other-Content-Types/Quick-Reference-CMS-1455-R.pdf

Which previously denied claims are eligible for rebilling?

The ruling applies to claims denied after March 13, 2013, claims with pending appeals, and claims denied prior to March 13th that are still within the appeals timeframe. On the latter point, if claims were within the appeals timeframe as of March 13th, do they remain eligible for rebilling even when they are beyond the appeals timeframe? As providers wait on billing instructions from CMS, claims that were still eligible for appeal as of March 13th will have their appeals timeframe expire. But in listening to the Hospital Open Door Forum, CMS’s comments seem to indicate that these claims would remain eligible for rebilling until the 180 days post denial date. CMS even indicated that denials from November 8, 2012, which is 125 days prior to March 13th (120 appeals timeframe plus 5 mailing days) would be eligible for rebilling under this rule until May 7, 2013 (180 days from 11/8/12). This means that providers would not have to appeal previously denied claims to maintain their billing rights under the Ruling. This gives CMS some time to develop billing instructions without impacting providers’ rebilling opportunities.

Can rehabilitative therapy services be included on a Part B inpatient claim?

Under current regulations, outpatient therapy services (PT, OT, and SLP services) are included in the list of “Part B only” services and may be billed on a Part B inpatient, 12x type of bill. Billing of therapy services will also be allowed under the Ruling. But, in the proposed rule for Part B rebilling, Medicare notes such “therapy” services are defined in section 1833 (a) (8) of the Act as outpatient services. Since “services specifically requiring an outpatient status” are not allowed to be billed on an inpatient claim under the proposed rule, rehabilitative therapy services (physical therapy, occupational therapy, and speech language pathology services) cannot be billed on the Part B inpatient claim once the proposed rule is finalized. So any therapy services that are provided to the patient after he/she is admitted will not be billable, unless Medicare further modifies the policy.

>