FAQs

Q. We have a situation where a patient has been placed in Outpatient Observation on a Friday afternoon with a diagnosis of Chest Pain r/o AMI. Our facility does not provide stress tests over the weekend but in the opinion of the admitting physician it would be unsafe to discharge the patient prior to having the stress test resulting in three midnight stays, as the test is not available until Monday. Under the 2 midnight rule, do we now submit an Inpatient Claim (Part A)?

A No. First of all, all Medicare claims submission must be driven by the written physician order. Therefore, before the facility can submit a Part A claim there must be documentation supporting the Inpatient Admission decision, including the order. Secondly, Section 1862(a)(1 )(A) of the Social Security Act statutorily limits Medicare payment to the provision of services that are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body. CMS has emphasized many times via memorandums, transmittals, and billing manuals that they will not reimburse for convenience or custodial care. In other words, if it is "inconvenient" for the facility to staff a Stress Lab on the weekends, CMS does not consider the time waiting as requiring "hospital services", but rather custodial in nature. In this instance it would be recommended to submit a bill supporting Outpatient Observation.


Q. What is Inpatient (IP)?

A.


Q. What is Observation (OBS or OBV)?

A.


Q. What is the difference between Extended Recovery and Observation?

A.


Q. What is Medical Necessity?

A.