Facilities: Effective Oct. 1, additional services may be payable for Medicare members moved from inpatient to outpatient

For claims with a date of service Oct. 1, 2019 or after, we may pay for certain Part B services for Medicare members if a determination is made post-discharge that a Medicare member should not have been admitted or if the admission is denied due to lack of medical necessity.

Previously, if a determination were made post-discharge that a patient’s hospital stay did not meet inpatient criteria, we would not allow for claim submissions using a type of bill 12x.

How should these services be billed?

Billable services should be submitted with bill type 12x.

Codes not included in this change

The revenue codes shown below represent services that are not billable as inpatient ancillary services and should not be submitted on a bill type 12x.

Revenue Codes not covered under inpatient Part B medical necessaity denials
 010x 011x 012x  013x 014x 015x 016x 017x
 018x 019x 020x 021x 022x 023x 024x 029x
 0390 0391 0399 045x 050x 051x 052x 054x
 055x 056x 057x 058x 059x 060x 0630 0631
 0632 0633 0637 064x 065x 066x 067x 068x
 072x 0762 082x 083x 084x 085x 088x 089x
 0905 0906 0907 0912 0913 093x 0941 0943
 0944 0945 0946 0947 0948 095x 0960 0961
 0962 0963 0964* 0969 097x 098x 099x 100x
 210x  310x            

*Revenue code 0964 is used by a hospital that has a CRNA exception.