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In-patient only surgeries

  1. #1
    Thumbs down In-patient only surgeries
    Exam Training Packages
    Is anyone familiar with a CMS listing of surgical procedures that can be billed only for inpatients? I have some surgeries performed out patient that are being denied stating they are only payable for POS 21 per CMS guidelines. I have searched the CMS website and found "references" to a list, but not the actual list. Anyone know where I can find this list? Thanks!

  2. #2
    North Carolina
    SI "C" indicates which CPT codes are inpatient

    When you get to the "download" section (bottom of page), click on:

    CY 2008 OPPS Final Addendum

    Column "D" (SI indicator) will indicate which procedures must be performed inpatient-"C"

  3. #3
    Louisville, KY
    Default Suggestions?
    This has finally gained some heightened attention at my facility. Basically I've spent the past year raising this flag as well as several others . . . point being, has anyone found a particularly successful model for preventing these SI "C" from being done OP?

    I would greatly appreciate any discussion we could open on that topic. It seems that I'm all out of approaches for a solution. (FYI, this situation also poses problem for our Pro-fee coding for obvious reasons--as my facility is responsible for rendering both "bills").


  4. #4
    The angle that seems to work best with my physicians is to show them the money. Keep track of the denials and tell them exactly how much revenue they lost by not doing the procedure inpatient. While my Drs don't mind performing charity work on occasion, they do NOT like working for free if it is only saving the insurance company.

  5. #5
    Rebecca, thanks!! None of the billers I spoke with knew of this list. It's like a whole new world. Though I have worked with coding for about 20 yrs I just became certified and it's the small (big) things like these that I am just getting in to.

    Is there a guide to this addendum somewhere that will tell me what all the indicators and columns mean? I swear I did look....I am apparently technically deficient on the CMS website.

    Thanks again! This will go a long way to working through some of the denials I've been seeing.

  6. #6
    North Carolina

    Is this helpful? You're not technically challanged. I attribute much of my knowledge to former mentors! We're a team in this field. Take care!

  7. #7
    Thanks again!

  8. #8
    Ok, one more question (for now). Is this list for physician charges only? We do billing for our facility & physicians. Facility is getting paid for the same CPT even though they billed OP, but physicians are getting denied. Before I rattle some cages with the provider reps, just wanted to check for any other words of wisdom.

  9. #9
    Louisville, KY
    Default More IP Only . . .
    In reality, the Indicators are designed for APC payment (facility). Now, that is, of course, per CMS.

    Other carriers have adopted the status indicator ideology, but in some ways appear to neglect the divergence between applying it consistently pro-fee vs. facility fee.

    Rattle the cages, I say. In truth, they really should match.

    I am in need of ideas . . . hoping you folks might help.

    InterQual (McKesson product) has its own (clinical) criteria for what is considered "Inpatient only" for procedures;I am attempting a matrix of some kind to compare/contrast/guide between InterQual and the CMS SI "C". Has anyone else developed such a tool and would you be willing to share the methods or successes of its use?

    Any assistance is appreciated.


  10. #10
    Charleston, South Carolina
    Cool FInal Rule
    You can also get the complete list thru the Final Rule. You will find links to this at

    Good Luck!

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