If outpatient claim and inpatient claim occur within 72 hours of each other and do not have the same diagnosis code, what should the provider do?

• A. Submit one combined claim
• B. No claim is necessary
• C. Submit two separate claims to Medicare
• D. Submit to Medicaid

Answer: (C)

The key idea is that when an outpatient encounter occurs within a short window before an inpatient admission and the diagnoses are not the same, Medicare requires reporting them as two distinct episodes of care. Each episode has its own coding and billing rules, so they must be submitted as separate claims to capture both the inpatient stay and the outpatient service accurately.

Why this works: the inpatient stay is billed under Part A with its own DRG and primary diagnosis, while the outpatient services are billed under Part B (or the outpatient claim workflow) with their own CPT/HCPCS codes and diagnosis. If you tried to merge them into one claim, the different diagnoses wouldn’t be reflected properly, which can lead to incorrect payment or compliance issues. Submitting two separate claims ensures each service is reported correctly and reimbursed appropriately.