Drug Coding Advisor-Fraud alert addresses outpatient surgery billing
The Health Care Financing Administration (HCFA) has issued a fraud alert (No. 99-09) stating acute care hospitals are billing outpatient surgery services as one-day inpatient stays.
According to the fraud alert, claims are being submitted using the inpatient type of bill (TOB) 11X with the "from date" equaling the "through date." Hospitals are using a patient status code of 01 (discharged from home or self-care/routine discharge). Ambulatory surgery claims should be billed using TOB 83X or 13X, according to HCFA.
"By billing Medicare for these services as inpatient, the hospital can increase their reimbursement by 83%, since payment is based on the diagnosis related group (DRG), rather than the applicable ambulatory surgical center (ASC) fee schedule (83X TOB) or the cost of charge percentage (13X TOB)," the fraud alert says.
"In addition, the beneficiary would be responsible for the current inpatient deductible, as opposed to the outpatient deductible and/or coinsurance amount, according to the alert.