Payment may be made under Part B for some medical and health services when furnished by a hospital (including Critical Access Hospitals) to an inpatient of the hospital, but only if payment for these services cannot be made under Part A.
Hospitals must bill Part B inpatient services on a 12X Type of Bill (TOB). Inpatient Part B services include inpatient ancillary services that do not require an outpatient status and are not strictly provided in an outpatient setting.
Services that require an outpatient status and are provided only in an outpatient setting are not payable inpatient Part B services, including Clinic Visits, Emergency Department Visits, and Observation Services (this is not a complete listing). These outpatient services are billed separately on a 13X TOB.
Part B payment may be made for ancillary services if:
The following services are billable on a 12X inpatient Part A ancillary claim:
The revenue codes shown in the charts below represent services that are not billable as Part A ancillary services and should not be submitted on a 12X inpatient Part A ancillary claim.
Revenue Codes - Not Allowed When Inpatient Claim Denied for Medical Necessity
Revenue Codes - Not Allowed Other Circumstances**
*In the case of revenue code 0964, this is used by hospitals that have a CRNA exception.
**Other circumstances includes services furnished by a participating hospital to an inpatient of the hospital who is not entitled to benefits under Part A, has exhausted his or her Part A benefits, or receives services not covered under Part A.
The Common Working File (CWF) will edit to ensure that Diabetic Self-Management Training (DSMT) services are not billed on a 12X TOB.
CMS IOM Publication 100-02, Benefit Policy Manual, Chapter 6, Section 10.2
CMS IOM Publication 100-04, Claims Processing Manual, Chapter 4, Section 240