Same Day / Same Service billing between outpatient (including ED) and inpatient/observation admissions
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Governs whether outpatient services (including ED visits) that occur within the 3-day (72-hour) or 1-day payment window before an inpatient/observation admission at the same hospital system may be billed separately; applies to Quartz commercial, level funded, Medicare Advantage, Medicaid, Medicare Select and Medicare Supplement lines of business and to participating and non‑participating providers unless an exception is stated.
No material clinical or coverage changes in this revision.
Same Day / Same Service Billing Criteria
Same Day/Same Service billing criteria
Quartz position on billing for outpatient/ED services within the Medicare 3-day/1-day payment window:
Exception (different specialties)
- When physicians are of different specialties and each is responsible for a different aspect of the patient's care, pay both visits if they are billed with different diagnoses.
Applicable Professional Billing Codes and Limits
| 99221-99223 | Initial hospital care codes — should be reported instead of both ED visit and initial hospital care on same day (per CMS guidance) |
Billing and Documentation Actions
Do not separately bill ED/outpatient services within 3-day window; include on inpatient claim
Do not bill separately for outpatient/ED services that occur within 3 calendar days (72 hours) preceding an inpatient/observation admission at the same hospital system; include ED services on the inpatient UB-04 claim rather than submitting a separate outpatient claim. Providers may be asked to submit supporting documentation during post-payment review, and Quartz may recoup payments or take corrective action for noncompliance.
- Facility (UB-04): include all ED services on the inpatient claim; do not submit a separate outpatient claim for the ED visit.
- Professional (CMS-1500): do not bill both an ED visit and an initial hospital care code (99221-99223) on the same day; report the initial hospital care code instead.
- Quartz conducts post-payment reviews and audits and may request supporting documentation; misuse or exceeding service limits may lead to recoupment or other corrective action.
Exception — pay separate visits for different specialties with different diagnoses
When physicians of different specialties are each responsible for different aspects of the patient's care, pay both visits if they are billed with different diagnoses.
- This is an exception to the one inpatient/observation care code per calendar date rule.
- Applies when physicians are in different specialties and have distinct responsibilities for care.
Defined Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.