Covered and Noncovered Services : Codes

Procedures Reimbursable Only as Inpatient Hospital Services

Certain surgical procedures are not reimbursed on an outpatient hospital facility claim. These services are reimbursed to professional providers only when performed in an inpatient hospital setting. These services are determined by outpatient hospital reimbursement methodology, EAPG.

The CMS website includes a list of the services that are only reimbursable when provided in inpatient hospitals.

Outpatient hospital providers billing on a UB-04 Claim Form and physician providers billing these services on professional claims (the 837P transaction or the 1500 Health Insurance Claim Form) are affected by this policy.

Note: Outpatient hospital claim reimbursement may be impacted by other coding data sets including the National Correct Coding Initiative's Medically Unlikely Edits, which can cause a detail on a claim to deny.

Policy information for CPT and HCPCS procedure codes is subject to change; providers should refer to the interactive maximum allowable fee schedule for the most current list of allowable procedure codes.