Inpatient-Only Services

Section 1833(t)(1)(B)(i) of the Social Security Act allows the Centers for Medicare & Medicaid Services (CMS) to define the services for which payment under the outpatient prospective payment system (OPPS) is appropriate. Services designated as inpatient only are not appropriate to be furnished in a hospital outpatient department.

Generally, but not always, inpatient-only services are surgical services that require inpatient care because of the:

• Nature of the procedure;
• Typical underlying physical condition of patients who require the service; or
• Need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged

No payment is made for an inpatient-only procedure submitted on the outpatient hospital type of bill, 13X. No payment is made for other services rendered on the same day as an inpatient-only procedure.

An example of an inpatient only service is CPT Code 33513, Coronary artery bypass, vein only; four coronary venous grafts.

Addendum E — Inpatient-Only

The designation of services to be inpatient only is open to public comment each year as part of the annual rulemaking process.

Procedures removed from the inpatient-only list may be furnished in either the inpatient or outpatient settings and continue to be payable when furnished in the inpatient setting.

There is no payment under OPPS for services that CMS designates to be inpatient-only services.

Inpatient-only services have an OPPS status indicator (SI) of C and listed in Addendum E of each year’s OPPS/ASC final rule located on the CMS Hospital Outpatient Regulations and Notices page.

Note: After clicking on the above link to hospital outpatient regulations and notices, click on the regulation number for the appropriate final rulemaking year requested (CMS-xxxx-FC).

Fig. 1. Hospital Outpatient Regulations and Notices page

Then: Click on the 20XX NFRM OPPS Addenda listed under related links.

Fig. 2. Downloads page

Click Accept on the License Agreement page. Once you click Accept a dialog box will appear asking you to Save or Open.

Once you open, you will get a box with a list of the addenda available.

Choose Addendum E (.xlsx or .csv); double click to open the file, then search for the code in question (CTRL+F to open search box).

Fig. 3. File Manager Window when Saving File

Exceptions
There are two exceptions to the policy of not paying for outpatient services rendered on the same day as an inpatient-only service paid under OPPS if the inpatient service had not been furnished.

Exception 1

Inpatient-only service defined in CPT as a separate procedure, and other services billed with the inpatient-only service that can be paid under OPPS:

• OPPS SI=T on the same date as the inpatient-only procedure; or
• OPPS SI = J1 on the same claim as the inpatient-only procedure

The inpatient-only service is denied, but payment is made for the separate procedure and any remaining payable OPPS services.

The list of separate procedures is available with the integrated outpatient code editor (I/OCE) documentation.

Status indicators may viewed in OPPS Addendum A and Addendum B and are updated quarterly. Each update outlines outpatient HCPCS codes, status indicators, APC groups, and OPPS payment rates. For additional information see: Coding Guidelines: Institutional Billing Resources for Addendums A, B, D1, E.

Exception 2

Inpatient-only service is furnished, but the patient dies before inpatient admission or transfer to another hospital.

The hospital reports the inpatient-only service with Modifier CA (Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission).

A single payment is made for all services reported on the claim, including the inpatient-only procedure.

Hospitals should report modifier CA on only one procedure.

Inpatient-Only Orocedure Performed in Outpatient Setting Within Payment Window
If an inpatient-only procedure is performed in the outpatient setting, and the patient is subsequently admitted as an inpatient, the inpatient-only procedure can be reported on the inpatient claim when the services are:

• Provided on the date of inpatient admission
• Provided within 3 days of inpatient admission

Deemed related to inpatient admission per the payment window policy.

References

• CMS IOM Pub. 100-04, Claims Processing Manual, Chapter 4, Section 10.12 (PDF)
• CMS IOM Pub. 100-04, Claims Processing Manual, Chapter 4, Section 180.7 (PDF)