Q&A: Timing of an inpatient order for an inpatient-only procedure

July 29, 2019
Medicare Web

Q: For an inpatient-only procedure, can the inpatient order be obtained the day after surgery, and if so, we are still allowed to bill as inpatient for the entire stay?

A: The services may be covered under the three-day payment window. Under this policy, as defined in the Social Security Act, certain outpatient services provided prior to an inpatient admission are considered to be covered costs of the inpatient.

Services that are not related to the reason for the inpatient admission are not covered under the three-day payment window. For example, a patient is treated in the emergency room because they were bitten by a dog. Two days later, that patient is admitted for an inpatient-only procedure. The services provided for the dog bite are not related to the inpatient-only procedure and therefore can’t be included on the inpatient claim.

Consider another, and quite common, example. A surgeon is performing a scheduled laparoscopic cholecystectomy, an outpatient procedure. After the procedure begins, the surgeon realizes she needs to perform an open cholecystectomy (CPT® 47600), an inpatient-only procedure. The surgeon can change the order to inpatient and it would be billed as an inpatient, but this must be done prior to discharge.

For more informaiton, see "Mastering the Inpatient-Only List: Strategies to Ensure Compliance and Avoid Denials."