The flip flop by CMS on the Inpatient Only List (IOL) has left many with their head spinning, and with good reason. First they remove 298 surgeries from the list, including many where patients always stay over two midnights, leading to education sessions and program redesigns to get status correct. Then CMS says “never mind” and puts most of them back.
As a reminder, the IOL only applies to traditional Medicare and not Medicare Advantage plans. The MA plans can elect to follow it but are not required to use it. In fact an MA plan can allow an inpatient only surgery to be done at an Ambulatory Surgery Center. Nope, don’t try to rationalize that. It’s an unexplainable decision by CMS but they make the rules.
But the question occasionally comes up about what to do about the status of the patient who is admitted for an inpatient surgery, either inpatient only or not, but then the surgery gets cancelled before being completed. If the inpatient only procedure was not done, should the status be switched to outpatient via condition code 44 or self-denial and rebill?
And as usual, the answer is “it depends.” Below I will use examples to describe the common scenarios, noting all are Medicare.
As can be seen, the determination of how to bill a surgery that is cancelled is not simple. One needs to consider the initial status order and the validity of that order, along with when the surgery was cancelled and why. Only then can the correct claim be submitted. It should also be noted that scenario 1 could have been avoided if the hospital had a policy that for scheduled inpatient admissions, the inpatient admission does not formally begin until the patient enters the operating room. In that case, the condition code 44 process would not be needed and an outpatient part B claim could be submitted for eligible services. This is outlined in a 2014 article found here.
Dr. Hirsch is vice president of regulations and education at R1 RCM Inc.
This article was reprinted from the American College of Physician Advisors Member’s Newsletter. ACPA information can be obtained at www.acpadvisors.org.
Dr. Ronald Hirsch is Vice President of the Regulations and Education Group at R1 RCM Inc. Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee. Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the third edition published in 2021.