Knowledge Base Article

Q:

How should hospitals handle inpatient billing when both covered and non-covered procedures are performed during a hospital inpatient admission? For example, an inpatient had a prostatectomy due to prostate cancer but a vasectomy was also performed during the surgery. Per a Medicare National Coverage Determination, vasectomies are non-covered by Medicare.

A:

Medicare instructs hospitals to remove the procedure code and related charges for the non-covered procedure from the inpatient claim.

Per the Medicare Claims Processing Manual, Chapter 1, section 60.2.1:

“…when a non-covered procedure is provided during an inpatient stay where a covered procedure is also performed, the claims processing system is unable to decipher what procedure code(s) is/are non-covered, so as to not consider such procedure(s) for payment (more specifically, to ignore non-covered procedures when grouping to the MS-DRG). Therefore, effective for inpatient discharges April 1, 2010, hospitals must only seek payment for covered services by removing non-covered procedure codes and related charges from the payable Type of Bill (TOB) 11X.”

If the hospital needs to submit a claim for the non-covered service to receive a denial, that procedure code and related charges should be reported on a no-pay claim (Type of Bill 11x) with the same From and Through Date as the covered 11x claim.