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Last Modified: 9/6/2024 Location: FL, PR, USVI Business: Part A

Hospital (inpatient and outpatient) -- additional resources

Listed below are additional resources identified specifically for hospitals.

First Coast resources

View recently released articles on billing and coverage from the First Coast Medicare website.

CMS resources

Visit the Hospital Center external link on the Centers for Medicare & Medicaid Services (CMS) website.
Web Pricers external link webpage -- provides Pricer information for hospitals and facilities providing services to Medicare beneficiaries.
Acute care inpatient hospitals
Acute inpatient prospective payment system (IPPS) external link webpage -- provides an overview and additional information regarding IPPS.
Acute care hospital IPPS payment policy Medicare Learning Network (MLN) educational tool -- provides a detailed overview of the acute care hospital IPPS.
Fiscal year (FY) 2023 inpatient and long-term care hospital PPS changes external pdf file -- MLN Matters (MM) article 12814 implements policy changes for FY 2023 IPPS and LTCH PPS, effective for hospital discharges occurring on or after October 1, 2022, through September 30, 2023, unless otherwise noted.
FY 2022 inpatient and long-term care hospital PPS changes external pdf file -- MLN Matters (MM) article 12373 implements policy changes for FY 2022 IPPS and LTCH PPS, effective for hospital discharges occurring on or after October 1, 2021, through September 30, 2022, unless otherwise noted.
Hospital Inpatient Admission Order and Certification external pdf file -- This CMS memorandum provided detailed guidance on inpatient certification & orders and applies to all inpatient hospital and critical access hospital (CAH) services unless otherwise specified.
CAHs
Visit the Critical Access Hospitals Center external link on the CMS website.
Information for Critical Access Hospitals booklet -- provides a detailed overview of the CAH payment methodology and explains how to properly document and bill for services.
Office of Inspector General (OIG) report (A-06-21-05003) external pdf file -- OIG found Medicare improperly paid CAHs and health care professionals for the same CAH services. Reminder -- A CAH can only bill for facility and professional outpatient services if the physician or practitioner reassigns their billing rights to them.
Additional processing procedure for adding a new provider-based location for CAHs external pdf file -- CR 11246 provides an update to the processing instructions for CAHs.
Hospital and CAH swing bed manual revisions external pdf file -- MM10962 clarifies policies related to hospitals and CAHs with respect to services furnished to swing bed patients, including policies related to pass-through reimbursement for Certified Registered Nurse Anesthetist (CRNA) services.
Outpatient hospitals
Hospital outpatient prospective payment system (OPPS) external link webpage -- discusses the authority for CMS to implement OPPS under Medicare for hospital outpatient services, certain Part B services furnished to hospital inpatients that have no Part A coverage, and partial hospitalization services furnished by community mental health centers.
Hospital outpatient prospective payment system MLN educational tool -- provides a detailed overview of the hospital OPPS.
Outpatient code editor (OCE) external link webpage -- provides an overview about the 'Integrated' Outpatient Code Editor (I/OCE).
Long-term care hospitals
Long-term care hospital PPS external link webpage -- provides an overview and additional information regarding LTCH PPS.
Long term care hospital prospective payment system MLN educational tool external link -- provides a detailed overview of the LTCH PPS.
FY 2023 inpatient and long-term care hospital PPS changes external pdf file -- MLN Matters (MM) article 12814 implements policy changes for FY 2023 IPPS and LTCH PPS, effective for hospital discharges occurring on or after October 1, 2022, through September 30, 2023, unless otherwise noted.
FY 2022 inpatient and long-term care hospital PPS changes external pdf file -- MM12373 implements policy changes for FY 2022 IPPS and LTCH PPS, effective for hospital discharges occurring on or after October 1, 2021, through September 30, 2022, unless otherwise noted.
Swing-bed facilities
Swing bed providers external link webpage -- provides an overview and additional information regarding swing bed facilities paid under the skilled nursing facility (SNF) PPS.
Swing bed services MLN fact sheet external pdf file -- provides a detailed overview of swing bed services.
Hospital and CAH swing bed manual revisions external pdf file -- MM10962 clarifies policies related to hospitals and CAHs with respect to services furnished to swing bed patients, including policies related to pass-through reimbursement for CRNA services.
Teaching hospitals
Transplant centers
Bypassing payment window edits for donor post-kidney transplant complication services external pdf file -- MM11312 directs MACs to implement logic ensuring they bypass payment window edits (three-day and 1-day) when processing claims for donor post-kidney transplant complications services.
Beneficiary notices external link -- Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Medicare program. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers.
Clinical Laboratory Improvement Amendments (CLIA) external link webpage -- Congress passed the CLIA in 1988 establishing quality standards for all laboratories testing to ensure the accuracy, reliability and timeliness of patient test results, regardless of where the test was performed. The CLIA regulations are based on the complexity of the test method; thus, the more complicated the test, the more stringent the requirements.
CMS Conditions for Coverage (CfCs) & Conditions of Participation (CoPs) external link -- CMS develops these health and safety standards that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs.
Office of Inspector General (OIG) reports highlight hospital billing issues external pdf file -- special edition article releases information regarding OIG reports, which focused on claims for right heart catheterizations with heart biopsies that used modifier 59 and claims for 96 or more continuous hours of mechanical ventilation.
Quality incentives and innovation models
Hospital Quality Initiative external link -- links to CMS hospital quality reporting programs for inpatient and outpatient facilities.
Hospital Readmissions Reduction Program (HRRP) external link -- Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions.
LTCH QRP external link -- provides important announcements and updates regarding the LTCH QRP.
Innovation Models external link -- The Innovation Center develops new payment and service delivery models in accordance with requirements of the Social Security Act. This link provides information on several specific demonstrations being conducted by CMS.
Special open door forums external link hosted by CMS

Professional associations

General resources

MedWatch external link -- Food and Drug Administration (FDA) medical recalls
PubMed external link
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.