Medicare and Medicare MA Inpatient denials - Change the patient status from IP to OP or leave?

I am trying to show the need for placing in observation first preventing these low case mix admissions that are denied since regulations below state when you have a patient admitted as IP but then is denied or self referred and bill part B you leave the patient status as ordered, Inpatient, in your MPI. My question is when you provide your facility monthly case mix index do you remove those cases from it or leave them?

CMS Rulings Department of Health

and Human Services

Centers for Medicare &

Medicaid Services


Ruling No.: CMS-1455-R Date: March 13, 2013

pg 12

Patient Status Under the Ruling

For the Part B claims billed under this Ruling, the beneficiary's patient status remains inpatient as of

the time of inpatient admission and is not changed to outpatient, because the beneficiary was

formally admitted as an inpatient and there is no provision to change a beneficiary's status after

she/he is discharged from the hospital. The beneficiary is considered an outpatient for services

billed on the Part B outpatient claim, and is considered an inpatient for services billed on the Part B

inpatient claim


  • Not sure I agree with your argument. If you put everyone in obs first, you are going to miss some short inpatient admissions that were appropriate for inpatient under the exceptions and lose out on the DRG.

    Also keep MA and Medicare separate with any data. MA plans are based on contract, Medicare uses 2 MN rule.

    But you raise a good point- your rebilled Medicare claim is a 121 claim but it pays as part B so I would not include it in any calculations of...anything.

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