Many hospital coding and billing services continue to struggle with the nearly 20-year-old definition of “other services” in the context of Medicare`s so-called 72-hour rule — more accurately defined as the three-day payment window. The resulting misuse forces many institutions to leave reimbursement money on the table instead of risking claims and possible fines. Wallace identifies three specific billing risks hospitals face in terms of compliance with the three-day rule. The first is the incorrect bundling of an ambulatory surgery with an inpatient claim, resulting in a severity overpayment of Medicare (MS)-DRG. She notes that many, but not all, fall into the MS-DRG 981 to 989 category, where surgery has nothing to do with the primary diagnosis. “These are the goals of RAC/MAC [Medicare administrative contractor], and the likelihood of an exam is high and accuracy is important,” she says. Several state Medicaid agencies include this policy as part of their physical payment method, which is why it`s important to stay informed. The Centers for Medicare and Medicaid Services (CMS) completed the three-day window policy on January 1, 2012, pursuant to Section 102 of the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (PACMBPRA) (Pub. L. 111-192). Miller, who agrees that the clarification has created new compliance challenges, suggests that employing doctors in hospitals and taking over doctors` offices by hospitals and health systems are the biggest barriers.
This is because these activities typically result in remote sites that, although wholly owned or operated by the hospital, use a variety of billing systems with no central means of identifying patients whose treatment may fall under the three-day rule. In particular, CMS noted that the regime also applies to services provided in doctors` offices or practices wholly owned or operated by a hospital. For example, the technical part of the pre-pick-up services must be included in the stationary invoice, although the fee can always be charged separately. The Centers for Medicare & Medicaid Services` (CMS) three-day rule, also known as the 72-hour rule, has remained unchanged since its inception in 1998. Despite its longevity, new questions have been raised about non-diagnostic ambulatory services and the three-day rule. Specifically, hospitals do not know whether non-diagnostic services provided during the three-day payment window that are not related to inpatient admission should be billed separately under Part B of Medicare. In response to their concerns, the CMS hosted an open house at the hospital on March 4. The forum provided clarification on the three-day rule and guidelines for billing non-diagnostic ambulatory services. This article provides an overview of CMS`s three-day rule and how diagnostic and non-diagnostic ambulatory services are properly billed prior to admission. That`s not all the rule change accomplished; It also highlighted compliance concerns. “The growing conversation that the rule change has sparked has made people realize how misunderstood the rule has been for some time,” says Susan Wallace, MEd, RHIA, CCS, CDIP, CCDS, Director of Compliance and Stationary Consultant with Administrative Consultants Services. This rule, officially referred to as the three-day payment period and sometimes the 72-hour rule, applies to diagnostic tests and other related services provided by the receiving hospital within three calendar days prior to the patient`s admission.
If a patient is admitted to hospital within three days of admission to hospital and uses diagnostic services, these services are considered hospital services and are included in the remuneration of inpatients, i.e. grouped patients. This rule applies to diagnostic tests or other services performed within three days prior to the patient`s admission to the hospital concerned. Diagnostic services covered by the 72-hour rule include: “Communication and collaboration as the patient transitions from outpatient to inpatient in the system, as well as a central repository of information and procedures to monitor and review information to ensure it complies with the three-day rule, Help identify requests that require consolidation, as well as those that may be billed separately for non-diagnostic services that are not clinically related. Miller said.