hospital services medicare patient outpatient hours prior hospital admission charges outpatient services

When a hospital provides services to a Medicare patient as an outpatient within 72 hours prior to a hospital admission charges for the outpatient services?

Your hospital status—whether you're an inpatient or an outpatient—affects how much you pay for hospital services (like X-rays, drugs, and lab tests). Your hospital status may also affect whether Medicare will cover care you get in a skilled nursing facility (SNF) following your hospital stay.

  • You're an inpatient starting when you're formally admitted to the hospital with a doctor's order. The day before you're discharged is your last inpatient day.
  • You're an outpatient if you're getting emergency department services, observation services, outpatient surgery, lab tests, or X-rays, or any other hospital services, and the doctor hasn't written an order to admit you to a hospital as an inpatient. In these cases, you're an outpatient even if you spend the night in the hospital.
Note 

Observation services are hospital outpatient services you get while your doctor decides whether to admit you as an inpatient or discharge you. You can get observation services in the emergency department or another area of the hospital.

The decision for inpatient hospital admission is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care. An inpatient admission is generally appropriate when you’re expected to need 2 or more midnights of medically necessary hospital care. But, your doctor must order such admission and the hospital must formally admit you in order for you to become an inpatient.

Each day you have to stay, you or your caregiver should always ask the hospital and/or your doctor, or a hospital social worker or patient advocate if you’re an inpatient or outpatient.

Here are some common hospital situations and a description of how Medicare will pay. Remember, you pay your 

deductible [glossary]

, 

coinsurance

, and 

copayment

.

SituationInpatient or outpatientPart A paysPart B paysYou're in the Emergency Department (ED) (also known as the Emergency Room or "ER") and then you're formally admitted to the hospital with a doctor's order.You come to the ED with chest pain, and the hospital keeps you for 2 nights. One night is spent in observation and the doctor writes an order for inpatient admission on the second day.You go to a hospital for outpatient surgery, but they keep you overnight for high blood pressure. Your doctor doesn't write an order to admit you as an inpatient. You go home the next day.Your doctor writes an order for you to be admitted as an inpatient, and the hospital later tells you it's changing your hospital status to outpatient. Your doctor must agree, and the hospital must tell you in writing—while you're still a hospital patient before you're discharged—that your hospital status changed from inpatient to outpatient.
Outpatient until you’re formally admitted as an inpatient based on your doctor’s order. Inpatient after your admission. Your inpatient hospital stay and all related outpatient services provided during the 3 days before your admission date. Your doctor services
Outpatient until you’re formally admitted as an inpatient based on your doctor’s order. Inpatient after your admission. Your inpatient hospital stay and all related outpatient services provided during the 3 days before your admission date. Your doctor services 
Outpatient Nothing Your doctor services and hospital outpatient services (for example, surgery, lab tests, or intravenous medicines)
Outpatient Nothing Your doctor services and hospital outpatient services
Note 

Remember, even if you stay overnight in a regular hospital bed, you might be an outpatient. Ask the doctor or hospital. You may get a Medicare Outpatient Observation Notice (MOON) that lets you know you’re an outpatient in a hospital or critical access hospital. You must get this notice if you're getting outpatient observation services for more than 24 hours.

The MOON will tell you why you’re an outpatient getting observation services, instead of an inpatient. It will also let you know how this may affect what you pay while in the hospital, and for care you get after leaving the hospital.

Note

The copayment for a single outpatient hospital service can’t be more than the inpatient hospital deductible. However, your total copayment for all outpatient services may be more than the inpatient hospital deductible.

When does a hospital provide services to a Medicare patient as outpatient?

When a hospital provides services to a Medicare patient as an outpatient within 72 hours before a related inpatient admission, charges for those outpatient services: must not be billed separately from the inpatient bill. Select the TRUE statement below with regard to Medicare hospital outpatient reimbursement.

When does a hospital charge a patient as an outpatient?

When a hospital provides services to a Medicare patient as an outpatient within 72 hours before a related inpatient admission, charges for those outpatient services: must not be billed separately from the inpatient bill.

What is considered medically necessary for outpatient care?

Medically necessary. diagnostic and treatment services you get as an outpatient from a Medicare-participating hospital. Covered outpatient hospital services may include: Emergency or observation services, which may include an overnight stay in the hospital.

How much does Medicare pay for outpatient care?

You usually pay 20% of the Medicare-approved amount for the doctor or other health care provider's services. You may pay more for outpatient services you get in a hospital than you’ll pay for the same care in a doctor’s office. However, the hospital outpatient Copayment for the service is capped at the inpatient deductible amount.

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