Medicare Part A
Subject to certain conditions, limitations, and exceptions the following inpatient hospital or inpatient Critical Access Hospital services are furnished to an inpatient of a participating hospital or participating CAH or, in the case of emergency services or services in foreign hospitals, to an inpatient of a qualified hospital:-
1) Bed and board.
2) Nursing and other related services.
3) Medical social services.
4) Drugs, biological, supplies, appliances, and equipment.
5) Certain other diagnostic or therapeutic services.
6) Transportation services, including transport by ambulance.
An inpatient is an individual who has been admitted to a hospital for the purpose of receiving inpatient hospital services. Generally, an individual is considered an inpatient if he or she is formally admitted as inpatient with the at least overnight and occupying a bed.
The physician or other practitioner responsible for an individual’s care at the hospital is responsible for deciding whether he or she should be admitted as an inpatient. The physician or other practitioner should work closely with hospital staff to ensure a proper admission as an inpatient following hospital admission protocols. The physician or practitioner should also use a 24-hour period as a benchmark by ordering admission for individuals who are expected to need hospital care for 24 hours or more and treating other individuals on an outpatient basis. The decision to admit an individual is a
complex medical judgment that requires the consideration of:
The individual’s medical history and current medical needs, including the severity of the signs and symptoms exhibited.
The medical predictability of something adverse happening to the individual;
The need for diagnostic studies that will assist in assessing whether the
individual should be admitted and that do not ordinarily require him or her to remain at the hospital for 24 hours or more;
The availability of diagnostic procedures at the time when and where the
individual presents;
The types of facilities available to inpatients and outpatients; The hospital’s by-laws and admissions policies; and
The relative appropriateness of treatment in each setting.
In the following situations, coverage of services on an inpatient or outpatient basis is not determined solely on the basis of length of time the individual actually spends in the hospital
Minor surgery or other treatment:-
When an individual with a known diagnosis enters a hospital for a specific minor surgical procedure or other treatment that is expected to keep him or her in the hospital for only a limited period of time, the individual is considered an inpatient only if the physician orders an inpatient admission regardless of his or her arrival hour at the hospital, or use of a bed, or if he or she remains in the hospital past midnight.
Renal dialysis treatments:-
Renal dialysis treatments are usually covered only as outpatient services for the individual who:
Resides at home; is ambulatory; has stable conditions; and Comes to the hospital for routine chronic dialysis treatments.
The following individuals who receive renal dialysis are usually inpatients:
those undergoing short-term dialysis until the kidneys recover from an acute illness and
those who have borderline renal failure and develop acute renal failure every time they have an illness and require dialysis.
An individual may begin dialysis as an inpatient and then progress to outpatient status. If non covered services that are generally excluded from Medicare coverage are
furnished in Non-Prospective Payment System hospitals, part of the billed charges or the entire admission may be denied. Appropriately admitted cases in Prospective Payment System hospitals include the following:
If care is non-covered because an individual does not need to be hospitalized, the admission will be denied and the Part A PPS payment will be made only under limitation on liability. Under limitation on liability, Medicare payment may be made when the provider and the beneficiary were unaware that the services were not necessary and could not reasonably be expected to know that they were not necessary. If an individual is appropriately hospitalized but receives only
non-covered, the admission is denied. An
admission that includes covered care, even if non covered care was also
furnished, will not be denied. Under PPS, Medicare assumes that it is paying for only the covered care furnished when covered services needed to treat and or diagnose the illness are furnished.
If a non covered procedure is furnished along with covered non routine care, a Diagnosis Related Group change rather than an admission denial might occur. If non covered procedures elevate costs into the cost outlier category, outlier payment will be denied in whole or in part.
If an individual receives items or services in excess of, or more expensive than, those for which payment can be made, payment is made only for the covered items or services or the appropriate PPS amount. This provision applies to inpatient services as well as all hospital services under Medicare Part A & Part B. If items or services are requested by the beneficiary, the hospital may charge him or her difference between the amount customarily charged for the services requested and the amount customarily charged for covered services.
If an individual requires extended care services and is admitted to a bed in a hospital, he or she is considered an inpatient of the hospital. The services furnished in the hospital will not be considered extended care services and payment may not be made unless the services are extended care services furnished pursuant to a swing bed agreement granted to the hospital by the Secretary of the Department of Health and Human Services.
1) Bed and board.
2) Nursing and other related services.
3) Medical social services.
4) Drugs, biological, supplies, appliances, and equipment.
5) Certain other diagnostic or therapeutic services.
6) Transportation services, including transport by ambulance.
An inpatient is an individual who has been admitted to a hospital for the purpose of receiving inpatient hospital services. Generally, an individual is considered an inpatient if he or she is formally admitted as inpatient with the at least overnight and occupying a bed.
The physician or other practitioner responsible for an individual’s care at the hospital is responsible for deciding whether he or she should be admitted as an inpatient. The physician or other practitioner should work closely with hospital staff to ensure a proper admission as an inpatient following hospital admission protocols. The physician or practitioner should also use a 24-hour period as a benchmark by ordering admission for individuals who are expected to need hospital care for 24 hours or more and treating other individuals on an outpatient basis. The decision to admit an individual is a
complex medical judgment that requires the consideration of:
The individual’s medical history and current medical needs, including the severity of the signs and symptoms exhibited.
The medical predictability of something adverse happening to the individual;
The need for diagnostic studies that will assist in assessing whether the
individual should be admitted and that do not ordinarily require him or her to remain at the hospital for 24 hours or more;
The availability of diagnostic procedures at the time when and where the
individual presents;
The types of facilities available to inpatients and outpatients; The hospital’s by-laws and admissions policies; and
The relative appropriateness of treatment in each setting.
In the following situations, coverage of services on an inpatient or outpatient basis is not determined solely on the basis of length of time the individual actually spends in the hospital
Minor surgery or other treatment:-
When an individual with a known diagnosis enters a hospital for a specific minor surgical procedure or other treatment that is expected to keep him or her in the hospital for only a limited period of time, the individual is considered an inpatient only if the physician orders an inpatient admission regardless of his or her arrival hour at the hospital, or use of a bed, or if he or she remains in the hospital past midnight.
Renal dialysis treatments:-
Renal dialysis treatments are usually covered only as outpatient services for the individual who:
Resides at home; is ambulatory; has stable conditions; and Comes to the hospital for routine chronic dialysis treatments.
The following individuals who receive renal dialysis are usually inpatients:
those undergoing short-term dialysis until the kidneys recover from an acute illness and
those who have borderline renal failure and develop acute renal failure every time they have an illness and require dialysis.
An individual may begin dialysis as an inpatient and then progress to outpatient status. If non covered services that are generally excluded from Medicare coverage are
furnished in Non-Prospective Payment System hospitals, part of the billed charges or the entire admission may be denied. Appropriately admitted cases in Prospective Payment System hospitals include the following:
If care is non-covered because an individual does not need to be hospitalized, the admission will be denied and the Part A PPS payment will be made only under limitation on liability. Under limitation on liability, Medicare payment may be made when the provider and the beneficiary were unaware that the services were not necessary and could not reasonably be expected to know that they were not necessary. If an individual is appropriately hospitalized but receives only
non-covered, the admission is denied. An
admission that includes covered care, even if non covered care was also
furnished, will not be denied. Under PPS, Medicare assumes that it is paying for only the covered care furnished when covered services needed to treat and or diagnose the illness are furnished.
If a non covered procedure is furnished along with covered non routine care, a Diagnosis Related Group change rather than an admission denial might occur. If non covered procedures elevate costs into the cost outlier category, outlier payment will be denied in whole or in part.
If an individual receives items or services in excess of, or more expensive than, those for which payment can be made, payment is made only for the covered items or services or the appropriate PPS amount. This provision applies to inpatient services as well as all hospital services under Medicare Part A & Part B. If items or services are requested by the beneficiary, the hospital may charge him or her difference between the amount customarily charged for the services requested and the amount customarily charged for covered services.
If an individual requires extended care services and is admitted to a bed in a hospital, he or she is considered an inpatient of the hospital. The services furnished in the hospital will not be considered extended care services and payment may not be made unless the services are extended care services furnished pursuant to a swing bed agreement granted to the hospital by the Secretary of the Department of Health and Human Services.
posted by MADHU at
April 27, 2011
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