0038 - Visits to Patients in Swing Beds: Incorrect Coding

Dynamic List Information
Dynamic List Data
Issue Name
0038 - Visits to Patients in Swing Beds: Incorrect Coding
Review Type
Automated
Provider Type
Professional Services
MAC Jurisdiction
All A/B MACs
Date
2017-02-23
RAC Type
Approved

Description

If the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply.  Hospital care codes billed while being in a swing bed will be recovered.

Affected Code(s)

99221-99223; 99231-99233; 99238-99239

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3.    42 CFR §405.929- Post-Payment Review
4.     42 CFR §405.930- Failure to Respond to Additional Documentation Request
5.    42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6.    42 CFR §405.986- Establishing Good Cause for Reopening
7.    Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9.D - Visits to Patients in Swing Beds
8.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9.    AMA CPT Codebook