Medicare Program; Medicare Hospital Insurance (Part A) and Medicare Supplementary Medical Insurance (Part B), 16614-16617 [2013-06159]

Agencies

• Centers for Medicare & Medicaid Services
• DEPARTMENT OF HEALTH AND HUMAN SERVICES

[Federal Register Volume 78, Number 52 (Monday, March 18, 2013)]
[Rules and Regulations]
[Pages 16614-16617]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2013-06159]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 405, 411, 412, 419, 424, and 489

[CMS-1455-NR]


Medicare Program; Medicare Hospital Insurance (Part A) and 
Medicare Supplementary Medical Insurance (Part B)

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice of CMS ruling.

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SUMMARY: This notice announces a CMS Ruling that establishes a policy 
that revises the current policy on Part B billing following the denial 
of a Part A inpatient hospital claim by a Medicare review contractor on 
the basis that the inpatient admission was determined not reasonable 
and necessary. This revised policy is intended as an interim measure 
until CMS can finalize a policy to address the issues raised by the 
Administrative Law Judge and Medicare Appeals Council decisions going 
forward. To that end, elsewhere in this issue of the Federal Register, 
we published a proposed rule entitled, ``Medicare Program; Part B 
Inpatient Billing in Hospitals,'' to propose a permanent policy that 
would apply on a prospective basis.

DATES: The CMS ruling announced in this notice is effective on March 
13, 2013.

FOR FURTHER INFORMATION CONTACT: Ann Marshall, (410) 786-3059, for 
issues related to payment of Part B inpatient and Part B outpatient 
services.
    David Danek, (617) 565-2682, for issues related to general appeals 
policy.
    If you have a question about a pending appeal, please contact the 
entity (that is, Medicare contractor, Qualified Independent Contractor 
(QIC), Administrative Law Judge (ALJ) or the Appeals Council) where 
your appeal is pending. For those cases that were remanded from an ALJ 
to a QIC, HHS' Office of Medicare Hearings and Appeals (OMHA) will post 
further information on its public Web site at www.hhs.gov/omha. The 
contact names listed will not have any information about specific, 
pending appeals.

SUPPLEMENTARY INFORMATION: The CMS Administrator signed Ruling CMS-
1455-R on March 13, 2013. This CMS Ruling, as well as other CMS Rulings 
are available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Rulings/. For the readers' convenience, the text of the CMS 
Ruling 1455-R is set forth in the Appendix to this notice of CMS 
ruling:

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: March 13, 2013.
Marilyn Tavenner,
Acting Administrator, Centers for Medicare & Medicaid Services.

    Note: The following appendix will not appear in the Code of 
Federal Regulations.

Appendix

CMS Rulings

Department of Health and Human Services

Centers for Medicare & Medicaid Services

Ruling No.: CMS-1455-R.
Date: March 13, 2013.

    Centers for Medicare & Medicaid Services (CMS) Rulings are 
decisions of the Administrator of CMS that serve as precedential 
final opinions, orders and statements of policy and interpretation. 
They provide clarification and interpretation of complex provisions 
of the law or regulations relating to Medicare, Medicaid, 
Utilization and Quality Control Peer Review, private health 
insurance, and related matters. They are published under the 
authority of the Administrator.
    CMS Rulings are binding on all CMS components, Part A and Part B 
Medicare Administrative Contractors (MACs), Qualified Independent 
Contractors (QICs), the Provider Reimbursement Review Board, the 
Medicare Geographic Classification Review Board, and on the Medicare 
Appeals Council and Administrative Law Judges (ALJs) who hear 
Medicare appeals. Rulings promote consistency in interpretation of 
policy and adjudication of disputes.
    In light of numerous recent Medicare Appeals Council and ALJ 
decisions on a recurrent Medicare payment issue and in association 
with this Ruling, CMS is concurrently issuing a proposed rule, 
entitled ``Medicare Program; Part B Billing in Hospitals'' 
addressing the policy of billing under Medicare Part B following a 
denial of a Medicare Part A hospital inpatient claim by a Medicare 
review contractor for the reason that an inpatient admission was not 
reasonable and necessary under section 1862(a)(1)(A) of the Social 
Security Act (the Act). This Ruling is effective as of the issuance 
date, and addresses the treatment of such claims and associated 
appeals until the effective date of the final regulations for the 
proposed rule entitled, ``Medicare Program; Part B Billing in 
Hospitals''.

Medicare Program

    Medicare Hospital Insurance (Part A) and Medicare Supplementary 
Medical Insurance (Part B).

[[Page 16615]]

Clarification of Billing Under Medicare Parts A and B

    Citations: Sections 1814, 1833, 1835, 1842, 1862, 1866, 1870, 
1879 and 1886 of the Social Security Act; 42 CFR Part 405 Subpart I, 
411.402, Part 412, 419.21, 424.44, and 489.21.

Background

    When a Medicare beneficiary arrives at a hospital in need of 
medical or surgical care, the physician or other qualified 
practitioner may admit the beneficiary for inpatient care or treat 
him or her as an outpatient. In some cases, when the physician or 
other qualified practitioner admits the beneficiary and the hospital 
provides inpatient care, a Medicare claims review contractor, such 
as a Medicare Administrative Contractor (MAC), a Recovery Audit 
Contractor (RAC), or the Comprehensive Error Rate Testing (CERT) 
Contractor, subsequently determines that the inpatient admission was 
not reasonable and necessary under section 1862(a)(1)(A) of the Act, 
and therefore denies the associated Part A claim for payment. Under 
such circumstances, Medicare payment policy has permitted hospitals 
to bill a subsequent ``Part B Inpatient'' claim for only a limited 
set of medical and other health services referred to as ``Part B 
Inpatient'' or ``Part B Only'' services. (For more information, see, 
Internet Only Manual (IOM) Pub. 100-02, Medicare Benefit Policy 
Manual (MBPM), Chapter 6, Section 10; Prospective Payment System for 
Hospital Outpatient Services, Proposed Rule, 63 FR 47560 (September 
8, 1998) and Final Rule, 65 FR 18444 (April 7, 2000); Changes to the 
Hospital Outpatient Prospective Payment System for Calendar Year 
2002, Proposed Rule, 66 FR 44698 through 44699 (August 24, 2001) and 
Final Rule, 66 FR 59891 through 59893, and 59915 (November 30, 
2001).)
    In an increasing number of cases, hospitals that have appealed 
these Part A inpatient claim denials to the ALJs and the Medicare 
Appeals Council have received decisions upholding the Medicare 
review contractor's determination that the inpatient admission was 
not reasonable and necessary, but ordering payment of the services 
as if they were rendered at an outpatient or ``observation level'' 
of care. These decisions effectively require Medicare to issue 
payment for all Part B services that would have been payable had the 
beneficiary been treated as an outpatient (rather than an 
inpatient), instead of limiting payment to only the set of Part B 
inpatient services that are designated in the MBPM. Moreover, the 
decisions have required payment regardless of whether the subsequent 
hospital claim for payment under Part B is submitted within the 
otherwise applicable time limit for filing Part B claims.
    The ALJ and Medicare Appeals Council decisions providing for 
payment of all reasonable and necessary Part B services under the 
circumstances previously described are contrary to CMS' longstanding 
policies that permit billing for only a limited list of Part B 
inpatient services and require that the services be billed within 
the usual timely filing restrictions (MBPM, Chapter 6, Section 10); 
Prospective Payment System for Hospital Outpatient Services, 
Proposed Rule 63 FR 47560 (September 8, 1998) and Final Rule, 65 FR 
18444 (April 7, 2000); Changes to the Hospital Outpatient 
Prospective Payment System for Calendar Year 2002, Proposed Rule, 66 
FR 44698 through 44699 (August 24, 2001) and Final Rule, 66 FR 59891 
through 59893, and 59915, (November 30 2001); Payment Policies Under 
the Physician Fee Schedule and Other Revisions to Part B for CY 
2011; Final Rule (75 FR 73449 and 73627, November 29, 2010). While 
decisions issued by the ALJs and the Medicare Appeals Council do not 
establish Medicare payment policy, we are bound to effectuate each 
individual decision. The increasing number of these types of 
decisions has created numerous operational difficulties. This Ruling 
establishes a standard process for effectuating these decisions and 
handling pending claims and appeals in the interim while CMS 
considers how to best address this issue going forward. The Ruling 
also addresses the scope of administrative review in these and 
other, similar cases. Until the final regulations entitled, 
``Medicare Program; Part B Inpatient Billing in Hospitals'' are 
promulgated, CMS, through this Ruling, acquiesces to the approach 
taken in the aforementioned ALJ and Appeals Council decisions on the 
issue of subsequent Part B billing following the denial of a Part A 
hospital inpatient claim on the basis that the admission was not 
reasonable and necessary. The policy announced in this Ruling 
supersedes any other statements of policy on this issue and remains 
in effect until the effective date of the regulations that finalize 
the proposed rule entitled, ``Medicare Program; Part B Inpatient 
Billing in Hospitals'', which we are issuing concurrently with this 
Ruling.

Ruling

Part B Hospital Inpatient Billing

    In light of the numerous recent ALJ and Medicare Appeals Council 
decisions previously described, this Ruling establishes a policy 
that revises the current policy on Part B billing following the 
denial of a Part A inpatient hospital claim by a Medicare review 
contractor on the basis that the inpatient admission was determined 
not reasonable and necessary. This revised policy is intended as an 
interim measure until CMS can finalize a policy to address the 
issues raised by the ALJ and Medicare Appeals Council decisions 
going forward. To that end, we issued a proposed rule entitled, 
``Medicare Program; Part B Inpatient Billing in Hospitals,'' today, 
to propose a permanent policy on a prospective basis once the 
proposed rule is finalized. Accordingly, this Ruling is effective 
only until such time as the aforementioned proposed rule is 
finalized.
    To date, under MBPM, Chapter 6, Section 10, a limited set of 
Part B inpatient services may be paid in the following 
circumstances:
     No Part A prospective payment is made at all for the 
hospital stay because of patient exhaustion of benefit days before 
admission.
     The admission was disapproved as not reasonable and 
necessary (and waiver of liability payment was not made).
     The day or days of the otherwise covered stay during 
which the services were provided were not reasonable and necessary 
(and no payment was made under waiver of liability).
     The patient was not otherwise eligible for or entitled 
to coverage under Part A.
    This Ruling applies only in the second circumstance listed 
previously, that is, when the admission was disapproved as not 
reasonable and necessary by a Medicare review contractor, and 
payment for the denied services was not made pursuant to section 
1879 of the Act (and provided the hospital's responsibility for 
repayment of an overpayment was not waived under section 1870 of the 
Act). Because the other circumstances for Part B inpatient billing 
listed in the MBPM are not the subject of the administrative appeals 
that this Ruling is designed to address (for example, when a 
beneficiary has no coverage under Part A because he or she exhausts 
Part A benefits), the existing policy applies in all other 
applicable circumstances, and a hospital may continue to bill for 
only the limited set of Part B inpatient services and must do so 
within the timely filing requirements.
    Pursuant to this Ruling, when a Part A inpatient claim for a 
hospital inpatient admission is denied by a Medicare review 
contractor because the inpatient admission was not reasonable and 
necessary, the hospital may submit a Part B inpatient claim for more 
services than just those listed in the MBPM, Chapter 6, Section 10, 
to the extent additional reasonable and necessary services were 
furnished. In this case, the hospital may submit a Part B inpatient 
claim for payment for the Part B services that would have been 
payable to the hospital had the beneficiary originally been treated 
as an outpatient rather than admitted as an inpatient, except when 
those services specifically require an outpatient status, for 
example, outpatient visits, emergency department visits, and 
observation services. Such services that require an outpatient 
status cannot be billed for the time period the beneficiary spent in 
the hospital as an inpatient and cannot be included on the Part B 
inpatient claim (see the following discussion of patient status).

Three-Day Payment Window Prior to the Inpatient Admission

    Current Medicare policy requires payment for certain outpatient 
services furnished on the date of an inpatient admission or during 
the 3-calendar days (or 1-calendar day for hospitals not paid under 
the hospital inpatient prospective payment systems (IPPS)) prior to 
the date of the inpatient admission (collectively, ``the 3-day (or 
1-day for non-IPPS hospitals) payment window prior to the inpatient 
admission'') to be bundled with the payment for the inpatient stay. 
See IOM Pub. 100-04, Medicare Claims Processing Manual (MCPM), 
Chapter 3, Section 40.3 and Chapter 4, Section 10.12.
    Under this Ruling, in cases for which no Part A payment is made 
because the Part A inpatient claim is denied on the basis that the 
inpatient admission was not reasonable and necessary, hospitals may 
bill separately for the outpatient services furnished during the 3-
day (or 1-day for non-IPPS hospitals) payment window prior to the 
inpatient admission as the outpatient services that they were, 
including observation and other

[[Page 16616]]

services that were furnished in accordance with Medicare's 
requirements. Because services provided during the 3-day (or 1-day 
for non-IPPS hospitals) payment window prior to the denied inpatient 
admission are outpatient services, these services may not be 
included on the Part B inpatient claim. Instead, hospitals may bill 
for these services on a Part B outpatient claim, which, in 
accordance with the policy announced in this Ruling, will not be 
subject to the usual timely filing restrictions discussed later in 
this Ruling. Hospitals may only submit claims for Part B inpatient 
and Part B outpatient services that are reasonable and necessary in 
accordance with Medicare coverage and payment rules. Hospitals must 
maintain documentation to support the services billed on a Part B 
inpatient claim for services rendered during the inpatient stay, in 
addition to those billed on a Part B outpatient claim for services 
rendered in the 3-day (or 1-day for non-IPPS hospitals) payment 
window prior to the inpatient admission.

Applicability

    This Ruling is effective on the date of issuance. It applies to 
Part A hospital inpatient claims that were denied by a Medicare 
review contractor because the inpatient admission was determined not 
reasonable and necessary, as long as the denial was made: (1) While 
this Ruling is in effect; (2) prior to the effective date of this 
Ruling, but for which the timeframe to file an appeal has not 
expired; or (3) prior to the effective date of this Ruling, but for 
which an appeal is pending. This Ruling does not apply to Part A 
hospital inpatient claim denials for which the timeframe to appeal 
expired prior to the effective date of this Ruling, and it does not 
apply to inpatient admissions deemed by the hospital to be not 
reasonable and necessary (for example, through utilization review or 
other self-audit).

Treatment of Pending Appeals and Appeal Rights

    We are aware that there are currently thousands of appeals 
pending that are subject to this Ruling. In determining the least 
burdensome approach for both hospitals and CMS, we are publishing 
this Ruling to provide hospitals with notice of their right to 
withdraw pending appeals of Part A claim denials that are subject to 
this Ruling, and instead submit Part B claims for payment. Requests 
for withdrawal of pending Part A claim appeals must be sent to the 
adjudicator with whom the appeal is currently pending, except where 
the appeal has been remanded from an ALJ to a QIC. Under this 
Ruling, appeals of Part A claim denials that were remanded from the 
ALJ level to the QIC level will be returned to the ALJ level for 
adjudication of the Part A claim appeal consistent with the scope of 
review explained later in this Ruling. QICs will send affected 
hospitals notice regarding this action. The Office of Medicare 
Hearings and Appeals (OMHA) will provide instructions for submitting 
requests for withdrawal of ALJ hearings, including cases that were 
remanded from an ALJ to a QIC. OMHA will post the instructions on 
its public Web site at www.hhs.gov/omha, or appellants may call any 
OMHA Field Office (included in the Notice of Hearing sent by an ALJ 
and on the OMHA Web site) to request a copy of the instructions by 
mail or facsimile. Until and unless adjudicators receive a request 
for withdrawal, they will continue processing all pending Part A 
appeals that are subject to this Ruling.
    In order to prevent duplicate billing and payment, a hospital 
may not have simultaneous requests for payment under both Parts A 
and B for the same services provided to a single beneficiary on the 
same dates of service. Thus, if a hospital chooses to submit a Part 
B claim for payment following the denial of a Part A inpatient 
admission, the hospital cannot also maintain its request for payment 
for the same services on the Part A claim. In this situation, the 
hospital must either choose to no longer pursue an appeal of the 
Part A claim denial (and thus, as a practical matter, any 
determination or appeal decision becomes final or binding, allowing 
the hospital to submit its Part B claim) or must withdraw any 
pending appeal request on the Part A claim denial prior to the 
submission of the Part B claim. The request to withdraw the pending 
Part A claim appeal must be sent to the entity currently processing 
such appeal, and the entity will issue a dismissal notice. If a 
hospital submits a Part B claim for payment without withdrawing its 
appeal request, the Part B claim for payment may be denied as a 
duplicate. Once the hospital submits a Part B claim, parties will no 
longer be able to appeal the Part A claim. However, parties will be 
able to exercise their appeal rights for the subsequent Part B claim 
under existing procedures in 42 CFR part 405 subpart I.
    If the hospital elects to withdraw its Part A appeal and submit 
a Part B claim, the hospital will have 180 days from the date of 
receipt of the appeal dismissal notice to submit the claim. If the 
appeal of the Part A claim remains pending, the hospital may submit 
a Part B claim if the Part A appeal is later withdrawn, or an 
unfavorable Part A appeal decision becomes final or binding, in 
which case, as explained later in this Ruling, the hospital will 
have 180 days from the date of receipt of the final or binding 
decision, or the date of receipt of the dismissal notice to submit 
the Part B claim.

Time Period Within Which a Provider Must Bill

    Consistent with longstanding policy, the filing of Part B 
inpatient and Part B outpatient claims would be considered new 
claims subject to the time limits for filing claims described in 
sections 1814(a)(1), 1835(a), and 1842(b)(3)(B) of the Act, and 42 
CFR 424.44. However, as an interim measure until the final rule 
entitled, ``Medicare Program; Part B Inpatient Billing in 
Hospitals'' can be issued, we are adopting (although not endorsing) 
the decisions of the ALJs and the Medicare Appeals Council that 
subsequent Part B rebilling by a hospital in situations covered by 
this Ruling is supported by concepts of adjustment billing. Under 
this approach, Part B inpatient and Part B outpatient claims that 
are filed later than 1-calendar year after the date of service are 
not to be rejected as untimely by Medicare's claims processing 
system as long as the corresponding denied Part A inpatient claim 
was filed timely in accordance with 42 CFR 424.44.
    If a hospital with a pending appeal for a Part A claim denial 
subject to this Ruling withdraws its appeal, it will have 180 days 
from the date of receipt of the dismissal notice to file its Part B 
claim(s). If a hospital with a pending appeal for a Part A claim 
denial subject to this Ruling does not withdraw its appeal, the 
hospital has 180 days from the date of receipt of the final or 
binding unfavorable appeal decision (or subsequent dismissal notice) 
to submit its Part B claim(s). For example, if an appellant receives 
an unfavorable reconsideration decision but decides not to request a 
hearing before an ALJ, or the time to request a hearing expires, the 
reconsideration decision becomes binding, and the Part B claim(s) 
may be filed within 180 days of the date of receipt of the 
reconsideration decision. If a hospital receives a denial of a Part 
A inpatient claim subject to this Ruling for which there is no 
pending appeal, and the denial is not subsequently appealed, the 
hospital will have 180 days from the date of receipt of the initial 
or revised determination on the Part A inpatient claim (that is, the 
date of the remittance advice) to submit its Part B claim(s). The 
date of receipt of an initial or revised determination, or an appeal 
decision or dismissal notice is presumed to be 5 days after the date 
of such notice or decision, unless there is evidence to the 
contrary.

Scope of Review for Part A Inpatient Claim Denials

    As noted earlier in this Ruling, a number of recent appeal 
decisions for Part A inpatient claim denials by a Medicare review 
contractor have affirmed the denial of the Part A inpatient 
admission, but ordered that payment be issued as if services were 
provided at an outpatient or ``observation level'' of care under 
Part B of the Medicare Program. These decisions ordered payment 
under Part B (or consideration of payment for services furnished 
that the contractor determined to be covered and payable under Part 
B), even though a Part B claim had not been submitted for payment. 
We note that these decisions are in conflict with existing policy. 
Thus, we are clarifying in this Ruling that hospitals are solely 
responsible both for submitting claims for items and services 
furnished to beneficiaries and determining whether submission of a 
Part A or Part B claim is appropriate. As specified in 42 CFR 
405.904(a)(2), once a hospital submits a claim, the Medicare 
contractor can make an initial determination and determine any 
payable amount. Under existing Medicare policy, if such a 
determination is appealed, an appeals adjudicator's scope of review 
is limited to the claim(s) that are before them on appeal, and such 
adjudicators may not order payment for items or services that have 
not yet been billed or have not yet received an initial 
determination. (See 42 CFR 405.920, 405.940, 405.948, 405.954, 
405.960, 405.968, 405.974, 405.1000, 405.1032,

[[Page 16617]]

405.1100, and 405.1128.) If a hospital submits an appeal of a 
determination that a Part A inpatient admission was not reasonable 
and necessary, the only issue before the adjudicator is the 
propriety of the Part A claim, not any issue regarding any potential 
Part B claim the provider has not yet submitted.

Patient Status Under the Ruling

    For the Part B claims billed under this Ruling, the 
beneficiary's patient status remains inpatient as of the time of 
inpatient admission and is not changed to outpatient, because the 
beneficiary was formally admitted as an inpatient and there is no 
provision to change a beneficiary's status after she/he is 
discharged from the hospital. The beneficiary is considered an 
outpatient for services billed on the Part B outpatient claim, and 
is considered an inpatient for services billed on the Part B 
inpatient claim.

Part A to Part B Rebilling Demonstration

    The Part A to Part B Rebilling Demonstration is being 
terminated. We will communicate to hospitals and contractors the 
details regarding termination of this Demonstration.

Operational Considerations

    We will issue operational and any other applicable regulatory 
guidance that is necessary to implement this Ruling, including the 
mechanics of how hospitals should bill for Part B inpatient and Part 
B outpatient services under this Ruling.

Instructions to Contractors

    All Medicare contractors including MACs and QICs must implement 
and follow this Ruling until such time as CMS addresses these issues 
further.
    Held: Pursuant to this Ruling, when a Part A claim for a 
hospital inpatient admission is denied by a Medicare review 
contractor because the inpatient admission was not reasonable and 
necessary, the hospital may submit a Part B inpatient claim for more 
services than just those listed in the MBPM, Chapter 6, Section 10, 
to the extent additional reasonable and necessary services were 
furnished. In this case, the hospital may submit a Part B inpatient 
claim for payment for the Part B services that would have been 
payable to the hospital had the beneficiary originally been treated 
as an outpatient rather than admitted as an inpatient, except when 
those services specifically require an outpatient status, for 
example, outpatient visits, emergency department visits, and 
observation services. Hospitals must submit their Part B claim 
within the timeframes specified in this Ruling. Further, where no 
Part A payment is made because the Part A inpatient claim is denied 
on the basis that the inpatient admission was not reasonable and 
necessary, hospitals may continue to bill separately for the 
outpatient services furnished during the 3-day (or 1-day for non-
IPPS hospitals) payment window prior to the inpatient admission, 
including observation and other services that were furnished in 
accordance with Medicare's requirements. In order to prevent 
duplicate billing and payment, a hospital may not have simultaneous 
requests for payment under both Parts A and B for the same services 
provided to a single beneficiary on the same dates of service. Thus, 
if a hospital chooses to submit a Part B claim for payment following 
the denial of a Part A inpatient admission, the hospital cannot also 
maintain its request for payment for the same services on the Part A 
claim. This Ruling applies to Part A hospital inpatient claims that 
were denied by a Medicare review contractor because the inpatient 
admission was determined not reasonable and necessary, as long as 
the denial was made: (1) While this Ruling is in effect; (2) prior 
to the effective date of this Ruling, but for which the timeframe to 
file an appeal has not expired; or (3) prior to the effective date 
of this Ruling, but for which an appeal is pending. This Ruling does 
not apply to Part A hospital inpatient claim denials for which the 
timeframe to appeal expired prior to the effective date of this 
Ruling, and it does not apply to inpatient admissions deemed by the 
hospital to be not reasonable and necessary (for example, through 
utilization review or other self-audit). For the Part B claims 
billed under this Ruling, the beneficiary's patient status remains 
inpatient as of the time of inpatient admission and is not changed 
to outpatient, because the beneficiary was formally admitted as an 
inpatient and there is no provision to change a beneficiary's status 
after she/he is discharged from the hospital. The beneficiary is 
considered an outpatient for services billed on the Part B 
outpatient claim, and is considered an inpatient for services billed 
on the Part B inpatient claim.

Effective Date

    This Ruling is effective March 13, 2013.

Dated:-----------------------------------------------------------------

Marilyn Tavenner,

Acting Administrator, Centers for Medicare & Medicaid Services.

[FR Doc. 2013-06159 Filed 3-13-13; 4:15 pm]
BILLING CODE P