Certified Revenue Cycle Representative (CRCR) Practice Exam

If outpatient diagnostic services are provided within three days of a Medicare beneficiary's admission to an inpatient hospital, what must happen to these charges?

1. They must be billed separately from the inpatient claim

2. They must be combined with the inpatient bill and paid under the MS-DRG system

3. They are automatically denied

4. They are placed on hold for review

The correct answer is: They must be combined with the inpatient bill and paid under the MS-DRG system

When outpatient diagnostic services are provided within three days of a Medicare beneficiary’s inpatient hospital admission, those charges must be combined with the inpatient bill and paid under the Medicare Severity Diagnosis Related Groups (MS-DRG) system. This is because Medicare has established rules that dictate that certain outpatient services that are related to an inpatient stay should not be billed separately. Instead, they are included in the overall payment for the inpatient admission. This approach helps ensure that the entirety of the patient’s care is encapsulated in one billing event, streamlining the payment process and avoiding duplicative billing. Under the MS-DRG system, hospitals are compensated a set rate for inpatient stays that takes into account the resources utilized during the hospital admission. By bundling these outpatient charges into the inpatient bill, it aligns with Medicare's intent to manage costs and provide a comprehensive payment solution for services that are medically linked.