Medicare Coverage of Inpatient Surgery
What It Is
Surgery performed while the patient is a hospital inpatient
Medicare Part A or a Medicare Part C plan covers charges from the hospital itself, including the daily room cost and laboratory, diagnostic, surgery, and anesthetic services, as well as the services of those physicians, nurses, and other providers who are members of the hospital staff.
Medicare Part B or a Medicare Part C plan covers the services of doctors -- including surgeons and anesthesiologists -- who participate in the surgery but who aren't members of the hospital staff.
If you have a Medicare Part C Medicare Advantage plan: Inpatient deductibles and co-payments, and co-payments for separately billed doctor and other services, may be different under a Medicare Part C plan than under Medicare Part A or Medicare Part B. To find out whether your plan has different deductibles or co-payments for inpatient surgery, contact the plan directly.
What Medicare Pays
The amount Medicare Part A pays for inpatient hospital charges for surgery is the same as for any other hospital stay, and it includes a patient deductible and co-payments. The amount Medicare Part A pays depends on the length of the stay, as well as on the patient's history of Medicare hospital coverage. Medicare Part B pays 80 percent of the Medicare-approved amount for a doctor's services that are billed separately from the hospital's charges.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.
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