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June 25, 2018

Part A Outpatient Date of Service Reporting and Split Billing

This is a reminder of the correct date of service to submit on your claim.

Outpatient Date of Service Reporting

All inpatient Part B and outpatient claims require a single line item date of service for each revenue code line reporting a Healthcare Common Procedure Coding System (HCPCS) reported in FL 45 of the UB-04 claim form or its electronic equivalent.

If a line item date of service is not reported on each revenue code line, or the line item dates of service reported are outside the statement-covers period, your claim will be returned.

Observation

If a period of observation (G0378) spans more than 1 calendar day, all hours for the entire period of observation must be included on a single line and the date of service for that line is the date observation care began.

Example: Observation was initiated in accordance with the order on 01/15/2017 at 10:00 pm and ended at 12:00 pm on 01/16/2017. The date of service reported on the observation room revenue code line is 01/15/17, the date observation services began.

Your observation services claim must also include one of the services listed below with a line item date of service on the same day or the day before observation services began.

An emergency department visit (Ambulatory Payment Classification (APC) 0609, 0613, 0614, 0615, 0616) or

A clinic visit (APC 0604, 0605, 0606, 0607, 0608); or

Critical care (APC 0617); or

Direct referral for observation care reported with HCPCS code G0379 (APC 0604); must be reported on the same date of service as the date reported for observation services.

No procedure with a 'T' status indicator can be reported on the same day or day before observation care is provided.

Emergency Room

The line item date of service for the Emergency Room (ER) service is the date the patient entered the ER, even if it spans multiple service dates.

For all other services related to the ER encounter (i.e., lab, radiology, etc.), the line item date of service reported is the date the service was actually rendered.

ER services provided to a beneficiary in a covered Part A Skilled Nursing Facility (SNF) stay is excluded from SNF Consolidated Billing. However, when services related to the ER encounter for a beneficiary in Part A SNF stay span more than one service date, the services performed on subsequent service dates are rejected by the Common Working Files (CWF) because the line item date of service (LIDOS) does not match the LIDOS reported with revenue code 045x. Therefore, in order to bypass the ER related services provided on a subsequent date, append modifier ET (Emergency Room) to those services. Reporting modifier ET will alert CWF that these services are ER related services performed on subsequent dates.

Clinical Lab Services - Specimen Collection

The date of service policy for clinical laboratory test/service must be the date the specimen was collected. 

If the collection spans two or more calendar dates, the date of service is the date the collection ended. 

Exceptions

Tests/Services Performed on Stored Specimens

If a specimen was stored for less than or equal to 30 calendar days from the date it was collected, the date of service of the test/service must be the date the test/service was performed only if:

  • The test/service is ordered by the patient's physician at least 14 days following the date of the patient's discharge from the hospital;
  • The specimen was collected while the patient was undergoing a hospital surgical procedure;
  • It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
  • The results of the test/service do not guide treatment provided during the hospital stay; and,
  • The test/service was reasonable and medically necessary for treatment of an illness.

If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the date of service must be the date the specimen was obtained from storage.

Chemotherapy Sensitivity Tests/Services Performed on Live Tissue

The date of service of a chemotherapy sensitivity test/service performed on live tissue must be the date the test/service was performed only if:

  • The decision regarding the specific chemotherapeutic agents to test is made at least 14 days after discharge;
  • The specimen was collected while the patient was undergoing a hospital surgical procedure;
  • It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
  • The results of the test/service do not guide treatment provided during the hospital stay; and,
  • The test/service was reasonable and medically necessary for treatment of an illness.

For purposes of applying this exception, a "chemotherapy sensitivity test" is defined as a test that requires a fresh tissue sample to test the sensitivity of tumor cells to various chemotherapeutic agents.

Advanced Diagnostic Laboratory Tests and Molecular Pathology Tests

The date of service for advanced diagnostic laboratory tests and molecular pathology tests must be the date the test was performed only if:

  • The test was performed following a hospital outpatient's discharge from the hospital outpatient department;
  • The specimen was collected from a hospital outpatient during an encounter;
  • It was medically appropriate to have collected the sample from the hospital outpatient during the hospital outpatient encounter;
  • The results of the test do not guide treatment provided during the hospital outpatient encounter; and
  • The test was reasonable and medically necessary for the treatment of an illness.

Outpatient Split Billing

There are times when an outpatient claim may cross over the provider's fiscal year end, the federal fiscal year end, or calendar year end.

The provider fiscal year is any 12 consecutive months chosen to be the official accounting period by a business or organization.  A fiscal year end can be the end of any quarter – March 31, June 30, September 30, or December 31.

The federal fiscal year is the 12-month period ending on September 30 of that year, having begun on October 1 of the previous calendar year.

A calendar year is the one-year period that begins on January 1 and ends on December 31.

Outpatient split billing is only required for services that span the calendar year end.  Outpatient split billing is not required for services that span the provider or federal fiscal year end.

Outpatient Split Billing Example

The patient was seen in the ER on 12/31/2017, was placed in observation on 12/31/2017 for 32 hours and discharged home on 1/1/2018. Submit the claims as follows:

1st claim (submitted first)

  • Type of bill = 132 (first in a series of claim)
  • From Date and Through Date= 12/31/2017 through 12/31/2017
  • Patient Status = 30 (still patient)

Note: All hours of observation are included on this claim.

2nd claim (wait till the first claim finalizes)

  • Type of bill = 134 (discharge bill)
  • From Date and Through Date = 1/1/2018 through 1/1/2018
  • Patient Status = 01 (discharged home)

Note: All ancillary charges that occurred on 1/1/2018 are included on this claim.

References

This document was developed through the A/B Medicare Administrative Contractor Provider Outreach & Education Collaboration Team. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and will assist the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.

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