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72 HOUR WINDOWII Medicare and Medicaid 3 Day Window Rule.

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Presentation on theme: "72 HOUR WINDOWII Medicare and Medicaid 3 Day Window Rule."— Presentation transcript:

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2 72 HOUR WINDOWII Medicare and Medicaid 3 Day Window Rule

3 Agenda PART II Understand Part I of the Medicare 3 day window rule. Identify outpatient diagnostic charges. Know when diagnostic charges need to be combined to an Inpatient account for billing.

4 Exclusions to the Rule There are some entities that are excluded from the Medicare 3 Day Window rule, they are: Inpatient Rehabilitation Facilities Long Term Care Hospitals Childrens Hospitals Cancer Hospitals Critical Access Hospitals

5 Medicare Guidelines Section 1886(a)(4) of the Social Security Act defines the operating costs of inpatient hospital services under the prospective payment system to include certain preadmission services furnished by the hospital (or by an entity that is wholly owned or operated by the hospital) to the patient up to 3 days before the day of the patients admission to the hospital.

6 Medicare Guidelines Preadmission services that are subject to the payment window (covered under the inpatient payment) include diagnostic services and non-diagnostic outpatient services that are related to a patients hospital admission.

7 Medicare Guidelines In March of 1998 CMS redefined non- diagnostic preadmission services as being related to the admission only when there is an exact match (for all digits) between the ICD-9 principal diagnosis codes for both the preadmission services and the inpatient stay. CMS Transmittal A

8 MEDICARE 3 DAY RULE ALL outpatient diagnostic charges that occur within 3 days of an inpatient admission MUST be combined with the inpatient account for billing.

9 What does that mean? That means that no matter what the diagnoses are on the accounts, the DIAGNOSTIC charges must be moved to and billed with the inpatient account.

10 Diagnostic Revenue Codes 254 drugs 255 drugs 30X Laboratory 31X Lab Pathology 32X Radiology 341 Nuclear Med 35X CT Scan 40X Other Imaging ( except 403 screening mammograms ) 46X Pulmonary Function 48X Cardiology 53X Osteopathic services 61X MRI 73X EKG 74X EEG 92X Other diagnostic

11 DIAGNOSTIC SERVICES Diagnostic services include: Radiology exams Lab EKGs Pulmonary Function Studies

12 REVIEW So to review, remember that no matter what the diagnosis is and even if the two accounts are unrelated, you ALWAYS combine outpatient diagnostic charges with the inpatient bill if they fall within the 3 day window.

13 EXAMPLE #1 On 10/07/06 a Medicare patient is seen in the ER of Hospital A with c/o a sprained ankle. The physician examines the patient. An x-ray of the ankle is done. An ace bandage is applied and the patient is discharged. On 10/09/06 the patient is admitted to Hospital A as an inpatient. He is c/o difficulty breathing. His final diagnosis is pneumonia.

14 EXAMPLE #1 continued The principal diagnosis on the ER account is Ankle Sprain The principal diagnosis on the IP account is 486 Pneumonia Since the principal diagnosis codes DO NOT match, ONLY the diagnostic charges will be combined with the inpatient bill

15 EXAMPLE # 1 continued Here are the charges on the ER account: Rev CodeCPT codeDescription 272 Ace Wrap RTX-Ray E/M Level

16 EXAMPLE #1 continued What charges if any from the emergency room visit should be combined with the inpatient charges for billing?

17 EXAMPLE #1 continued In this example there was no principal diagnosis match. The only charge that will have to be combined with the inpatient account is the x-ray charge. Revenue code 320 is the only diagnostic revenue code that was charged. The ER account can be billed alone with revenue codes 272 and 450.

18 EXAMPLE #2 Patient presents to Hospital A for lab work on 09/27/06. A CBC is done. Patient is admitted to Hospital A as an inpatient on 09/31/06.

19 EXAMPLE #2 continued These accounts should not be combined, The inpatient admission was 4 days after the outpatient lab work was done. Since this doesnt fit into the 3 day/72 hour window the accounts are billed separately.

20 EXAMPLE #3 Patient comes to the hospital for a CT scan of the chest with contrast on 08/15/06. The principal diagnosis is pneumonia (486). Patient is admitted as an inpatient to the same hospital on 08/17/06. The principal diagnosis is lung cancer (162.9).

21 EXAMPLE #3 continued The charges for the outpatient radiology account are: RC 352CPT CODE CT Chest with contrast RC 636Q9950 LOCM

22 EXAMPLE #3 continued Both the CT scan and the contrast charges will need to be moved to the inpatient account for billing. The contrast is considered incidental to the CT scan. Any ancillary charges that are part of a diagnostic procedure have to be moved and combined with the inpatient account. Medicare does not allow incidental charges to be billed alone.

23 EXAMPLE #4 A patient comes to Hospital A for a chest x-ray on 09/08/06. On 09/10/06 the same patient is seen in the emergency room at Hospital A and treated for bronchitis before being discharged home.

24 EXAMPLE #4 continued Since the chest x-ray was done within 72 hours of the patients emergency room visit, should the x-ray be combined with the emergency visit for billing?

25 EXAMPLE #4 continued In this example the x-ray charges should not be combined with the emergency room account. Both of these visits are outpatient visits. Since there is no inpatient visit these accounts do not fall into the 3 day window rule.

26 EXAMPLE #5 A patient is seen in the emergency room of Hospital A for c/o back pain on 09/11/06. The same patient is then admitted to Hospital B for back surgery as an inpatient on 09/13/06.

27 EXAMPLE #5 continued There are diagnostic charges on the emergency room account. Should the diagnostic charges be combined with the inpatient account?

28 EXAMPLE #5 continued Hospital A and Hospital B are separate entities with different owners. Since the patient was seen at different hospitals the accounts although within the 3 day window would not be combined for billing.

29 POINTS TO REMEMBER Not all facilities are included in the 3 day window rule. The patient must be seen as an outpatient within 3 days of an inpatient admission at the same facility or a facility owned and operated by the same company. All diagnostic charges that are within the 3 day window must be combined to the inpatient account for billing.

30 Diagnostic Services? Which outpatient services would always be combined with an inpatient admission? Diagnostic Ultrasound Screening Mammogram Non-related Physical Therapy Laboratory Testing Maintenance Dialysis Diagnostic Pulmonary Function Testing

31 Diagnostic Services? ****Diagnostic Ultrasound ****Laboratory Testing ****Diagnostic Pulmonary Function Testing Screening Mammogram Non-related Physical Therapy Maintenance Dialysis

32 Diagnostic Services? Which of these outpatient services would always be combined with an inpatient admission? EKG Ambulance Transport CT Scan Urinalysis E/M Level

33 Diagnostic Services? **** EKG **** CT Scan **** Urinalysis Ambulance Transport E/M Level

34 72 HOUR WINDOW 72 HOUR WINDOW Medicare and Medicaid 3 Day Window Rule If you have any questions are concerns regarding this course, please contact Sandy Sage, RN at


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