Bill Inpatient or Outpatient Services

To help avoid denials, National Government Services has compiled information regarding references that will aid in determining whether to bill inpatient or outpatient services.

CMS Medicare Learning Network (MLN) – Fact Sheet

CMS MLN has created a fact sheet that is a very helpful reference that describes the Two-Midnight Rule. This rule established Medicare payment policy regarding the benchmark criteria to use when determining whether inpatient admission is reasonable and necessary for purposes of payment under Medicare Part A.

CMS Inpatient Only and Procedures Acceptable as Performed in Outpatient Setting

Another helpful tool is the CMS Hospital Outpatient PPS Addendum B Updates. This listing can be used to aid in determining if care can be billed as inpatient or outpatient services. Using the HCPCs code that best describes the procedure needed, find the code and the associated column that lists the “SI” – Status Indicator. SI “C” is used to classify procedures that can only be billed to Medicare in an inpatient hospital setting. These procedures have been determined to require the level of intensity of services in the inpatient hospital setting. Procedures listed with “SI” other than “C” are considered to be appropriate in an outpatient setting. Level of intensity of services would still need to be assessed by the admitting physician in these cases.

Reviewed 11/14/2024