Medicare CMS Inpatient Only List Information

In this article...
  • The Medicare CMS inpatient only list provides information on inpatient procedures covered by Medicare. Learn more about the CMS list and its 2021 changes.

The Centers for Medicare and Medicaid Services (CMS) is an organization that administers Medicare and Medicaid. As a federally run agency and part of the United States Department of Health and Human Services, CMS is responsible for providing health coverage and enforcing compliance to help prevent fraud and abuse within the federal healthcare system.

Each year, CMS establishes a list to define services and procedures as inpatient or outpatient for Medicare. 

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What Is the CMS Inpatient Only List?

The CMS Inpatient Only List is a list of complex procedures that Medicare plans will only cover if performed in hospital inpatient settings.

These procedures are generally covered under Medicare Part A as established by CMS, but other procedures that CMS and Medicare determine are less complex may automatically default to Medicare Part B as an outpatient service. 

Some inpatient procedures on the CMS Inpatient Only List include: 

  • Coronary artery bypass grafting
  • Heart valve repair
  • Heart valve replacement
  • Gastric bypass surgery for obese individuals
  • Heart transplant
  • Maxillectomy procedures (jaw tumor removal)
  • Nasal and sinus endoscopic surgeries

What Are the Medicare Inpatient Only List 2021 Changes?

In January 2021, CMS removed 298 items from its Inpatient Only List, including 266 musculoskeletal procedures, 16 anesthesia codes and 16 procedures recommended by the Hospital Outpatient Payment Panel with an effective backdate of Jan 1, 2022. However, feedback from stakeholders caused CMS to pause the elimination and keep the list as-is.

A final ruling added all items back to the list except for lumbar spine fusion surgery, shoulder joint reconstruction and ankle joint reconstruction, along with the three corresponding anesthesia codes for the three procedures.

It's important to note that procedures removed from the Medicare Inpatient Only List may be eligible for review due to Medicare's two-midnight rule, which refers to inpatient hospital stays that last at least two midnights following admission.

Individuals scheduled for surgical procedures removed from the CMS Inpatient Only List that may fall under the 2-midnight rule should consult with Medicare to determine their specific coverage options. 

Which Medicare Plans Are Regulated by CMS?

The Medicare plans regulated by CMS include Medigap (Medicare Supplement) plans, Medicare Advantage and Medicare Cost plans. CMS also regulates managed care marketing, healthcare prepayment plans (HCPP), private for-fee service plans, and medical savings account plans (MSA). 

What Is the Difference Between the FDA and CMS?

CMS and FDA are both regulatory agencies that focus on evidence-driven delivery of healthcare products and services. However, the FDA ensures proper regulation of the marketing and use of pharmaceutical products and medical products while CMS regulates the reimbursement practices for healthcare products and services through Medicare and Medicaid. 

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