Clarification of Part A to Part B Rebilling of Inpatient Claims

June 1, 2013
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Rick Gawenda
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Effective March 13, 2013 CMS Ruling 1455-R established an interim process allowing all hospitals to bill Medicare for Part B services after receiving a denial for a Part A inpatient admission claim as not reasonable and necessary.

This process applies to Part A hospital inpatient claims that were denied by a Medicare review contractor because the inpatient admission was determined not reasonable and necessary, as long as the denial was made: (1) while this Ruling is in effect; (2) prior to the effective date of this Ruling, but for which the timeframe to file an appeal has not expired; or (3) prior to the effective date of this Ruling, but for which an appeal is pending. Ruling CMS-1455-R does not apply to Part A hospital inpatient claim denials for which the timeframe to appeal expired prior to the effective date of this Ruling, and it does not apply to inpatient admissions deemed by the hospital to be not reasonable and necessary (for example, through utilization review or other self-audit).

Hospitals may now submit a Part B 13x outpatient type of bill (TOB) for services provided in the three-day payment window prior to the inpatient admission, e.g. observation. Additionally providers may submit the ancillary 12x TOB for any medically necessary Part B services provided during the inpatient stay.

For claims that meet the above guidelines and Returned to Provider (RTP’d) with reason code 31809 because the provider file was not updated, resubmit the claim via 5010 electronic submission, hard copy UB-04, or if you have Direct Data Entry (DDE) F9 the claim back into processing.

For claims RTP’d with reason code 10404 remove the W2 Condition Code and resubmit the claim via one of the above methods.  The W2 condition code is not in effect during the interim process period of 1455-R.

Quick Reference Guide

CMS Ruling 1455-R Fact Sheet


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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

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