CMS Establishes New 3-day Payment Window Modifier

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  • January 13, 2012
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The Centers for Medicare & Medicaid Services (CMS) has established new payment modifier PD Diagnostic or related nondiagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days. Physicians, suppliers, and providers are now required to append modifier PD to preadmission diagnostic and admission-related nondiagnositic services reported with HCPCS Level II or CPT® codes subject to the 3-day payment window policy.
Modifier PD is available for claims with dates of service on or after Jan. 1, 2012. This is changed from the effective date of Jan. 10, 2012, established in CMS Transmittal 2297. CMS advises entities to begin coordinating their billing practices and claims processing procedures with their hospitals to ensure compliance with the 3-day payment window policy no later than for claims received on or after July 1, 2012.
When modifier PD is present on claims for service, Medicare will pay:

  • Only the professional component (PC) for CPT®/HCPCS Level II codes with a technical component (TC)/PC split that are provided in the 3-calendar day (or, 1-calendar day) payment window; and
  • The facility rate for codes without a TC/PC split.

See MLN Matters MM7502 for background information relating to the 3-day window payment policy. AAPC’s Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CHCC, CENTC, offers additional guidance.

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No Responses to “CMS Establishes New 3-day Payment Window Modifier”

  1. Sylvia S Keller, CPC says:

    Is the -PD modifier appropriate for Hospital Outpatient services such as Pre-Admission labs or is it only for use in non-hospital facilities?