Wednesday, May 18, 2016

Payment for service incident to Admission


Policy
Services rendered prior to a related inpatient admission are considered incidental to admission and are included in the inpatient reimbursement rate.
Services that are incidental to an admission include:
• Surgical day care
• Observation stay
• Emergency room care
• Diagnostic and/or testing services
Pre-admission services may be subject to post-payment audits and retractions.


Per Diem
Incidental services that are provided within one day of a related inpatient admission are included in the inpatient per  diem reimbursement.

An observation stay that converts to an inpatient admission before midnight of the same day is included in the inpatient per diem rate and is not separately reimbursed.

An observation stay that converts to an inpatient admission after midnight of the observation day is not included in the per diem rate and is separately reimbursed.


Case Rate and Diagnosis-Related Groups (DRG)
• Diagnostic services that are provided within three days of an inpatient admission are included in the inpatient Case rate or DRG reimbursement.
• Non-diagnostic services related to the principal diagnosis that are provided within three days of an inpatient admissions are included in the inpatient case rate or DRG reimbursement.
• Any ambulatory day care, radiology or laboratory procedures that result in an inpatient admission are included in the inpatient case rate or DRG reimbursement

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