1. Medicare and Medicaid 3 Day Window Rule
72 HOUR WINDOW II
Medicare and Medicaid
3 Day Window Rule

2. 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.

3. 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
Children’s Hospitals
Cancer Hospitals
Critical Access Hospitals

4. 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 patient’s admission to the hospital.

5. 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 patient’s hospital admission.

6. 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

7. 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.

8. 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.

9. 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

10. DIAGNOSTIC SERVICES Diagnostic services include: Radiology exams Lab
EKG’s
Pulmonary Function Studies

11. 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.

12. 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.

13. 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

14. EXAMPLE # 1 continued Here are the charges on the ER account:
Rev Code CPT code Description
Ace Wrap
RT X-Ray
E/M Level

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

16. 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.

17. 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.

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

19. 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).

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

21. 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.

22. 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.

23. EXAMPLE #4 continued
Since the chest x-ray was done within 72 hours of the patient’s emergency room visit, should the x-ray be combined with the emergency visit for billing?

24. 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.

25. 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.

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

27. 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.

28. 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.

29. 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

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

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

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

33. Medicare and Medicaid 3 Day Window Rule
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