HI 00601.005 Covered Part A Inpatient Hospital Services

Citations:

Act—Sec. 1861(b)

20 CFR Sections 405.103, 405.161

Patients covered under hospital insurance are entitled to have payment made on their behalf on a reasonable cost basis for inpatient hospital services. An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a person is considered an inpatient if formally admitted as an inpatient with the expectation that he will remain at least overnight and occupy a bed even though it later develops that he can be discharged or transferred to another hospital and does not actually use a hospital bed overnight. However, there are exceptions to the general rule:

A. Hospitalization for minor surgery

When a patient with a known diagnosis enters a hospital for a specific minor surgical procedure or other treatment that is expected to keep him in the hospital for only a few hours (less than 24), and this expectation is realized, he is considered an outpatient regardless of: the hour of admission; whether or not he used a bed; and whether or not he remained in the hospital past midnight.

B. Hospitalization for renal dialysis

Renal dialysis treatments are usually outpatient services but may be inpatient services. A patient who is staying at his home, who is ambulatory, whose condition is stable and who comes to the hospital for routine, chronic dialysis treatments, and not for a diagnostic workup or a changed in therapy, is considered an outpatient. On the other hand, a patient undergoing short-term dialysis until his kidneys recover from an acute illness (acute dialysis), or a person with borderline renal failure who develops acute renal failure every time he has an illness and requires dialysis (episodic dialysis), is always an inpatient. A patient may begin dialysis as an inpatient and then progress to an outpatient status.

If doubt exists as to a particular patient's status after these criteria are applied, a medical opinion is obtained by the intermediary.NOTE: When patients requiring extended care services occupy beds in a hospital, they are considered inpatients of the hospital. In such cases, the services furnished in the hospital are not considered extended care services, and payment may not be made under the program for such services. However, if a bed in a participating SNF is not available, the beneficiary's continued stay in the hospital would be medically necessary and program payment could be made.

C. Hospitalization for pregnancy

The 1972 Amendments extended coverage to disabled beneficiaries. As a result, beneficiaries in the child-bearing years are included for the first time. Reasonable and necessary services associated with pregnancy are covered and reimbursable under Medicare. The increased possibility of illness or injury which accompanies this condition is well recognized, and medical supervision is required throughout pregnancy and for a brief period beyond. Skilled medical management is appropriate throughout the events of pregnancy, beginning with diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care. Similarly, in the event of termination of pregnancy, regardless of whether terminated spontaneously or whether abortion is induced for therapeutic or elective reasons, the need for skilled medical management and/or medical services is equally as important as in t