A CPT procedure on the CMS inpatient-only list is performed. What is the key outpatient payment implication for hospital OPPS?
Select an answer to reveal the explanation.
Short Explanation
Inpatient-only means exactly that for hospital OPPS—Medicare isn’t buying that surgery as an outpatient facility service. It’s on a special list that points toward inpatient admission for payment. A modifier won’t magic it onto an outpatient APC.
Full Explanation
When a CPT procedure on the CMS inpatient-only list is performed, the key outpatient payment implication is that the procedure is generally not payable under OPPS and typically requires inpatient admission for facility payment under IPPS rules when covered. Municipal surgical services must honor the inpatient-only list rather than treating listed codes as routine same-day surgery. Expecting a higher APC than any other surgery fails because inpatient-only procedures are generally excluded from OPPS payment, not paid via an elevated APC. Appending modifier -25 does not convert an inpatient-only procedure into an outpatient-payable facility service. The list is a facility OPPS concept affecting hospital outpatient claims, not merely a professional-claim rule. Exam caveat: inpatient-only list items test setting-of-care payment constraints for facility claims under OPPS versus IPPS. Operational check: before scheduling or coding a listed procedure as hospital outpatient at a civic facility, confirm inpatient-only status, coordinate admission status with utilization review, and do not rely on E/M modifiers to force OPPS payment. Track near-miss outpatient bookings of inpatient-only codes for education with OR scheduling and surgeons.