by Jared Staheli
June 25th, 2015
Social admissions for patient and family convenience are not covered by Medicare. They are not billable to Medicare by IHS providers (including CAHs) on either TOB 11X (hospital inpatient) or 12X (hospital inpatient Part B). For admissions before surgery, only the scheduled surgery and related services may be billed on TOB 83X (ambulatory surgical center) if the surgery is performed on an outpatient basis and on TOB 11X if the surgery is performed on an inpatient basis. When placing a patient in a room for social reasons after discharge from an inpatient stay this portion of inpatient care may not be billed to Medicare. Medicare disallows payment for inpatient Medicare Part B ancillary services during a social admission stay when there is another bill from a different facility for an outpatient service. A TOB 12X from the admitting facility with a 13X (hospital outpatient) TOB from another hospital, a 72X (hospital based or freestanding renal dialysis center) TOB from a renal dialysis facility (RDF). Consequently, CWF will send an informational unsolicited response (IUR) to the designated FI on receipt of the 13X or 72X bill.
Medicare also disallows payment for inpatient Part B ancillary services during a social admission stay when a TOB 12X has a line item date of service (LIDOS) that is equal to or one day following the discharge date on a TOB 11X for the same provider. The CWF sends an IUR to the designated FI in this situation.
The CWF bypasses both of these edits when the beneficiary is not entitled to Medicare Part A at the time the services on TOB 12X are rendered.
See Chapter 4, §240.2 of Pub. 100-04, Medicare Claims Processing Manual, for more information on social admissions.
NOTE: Effective for dates of service on or after January 1, 2008, the FI no longer processes claims for IHS ASCs (TOB 83X). All IHS ASC providers must submit their claims to the carrier.