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Thread: Three day window rule

  1. #1
    Join Date
    Apr 2007
    Jackson, Tn

    Default Three day window rule

    AAPC: Back to School
    New CMS decisions about the 3 day window for inpt codes is confusing. We have doctors that are employed by a hospital and I'm trying to figure out what we can't code now.
    Any help?

  2. #2
    Join Date
    Apr 2007


    This is what's posted on our Medicare contractor's website, see link:


    I pasted it in also, in case the link didn't work:

    MM7142 – Clarification of Payment Window for Outpatient Services Treated as Inpatient Services

    Effective for dates of service on or after June 25, 2010, the following is clarification of Medicare policy for payment of outpatient services on either the date of an inpatient admission or during the three calendar days immediately preceding an inpatient date of admission:

    Under the three-day payment window, a hospital (or an entity that is wholly owned or wholly operated by the hospital) must include on the inpatient claim the diagnoses, procedures and charges for all outpatient diagnostic services and admission-related outpatient non-diagnostic services provided during the payment window.
    All services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the same date of the inpatient admission are deemed related to the admission and are not separately billable.
    Outpatient non-diagnostic services, other than ambulance services and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the first, second and third calendar days (first calendar day for non-subsection (d) hospitals) preceding the date of a beneficiary’s admission are deemed related to the admission and must be billed on the inpatient claim.
    A hospital can attest to specific non-diagnostic services as being unrelated to the inpatient hospital claim (the preadmission non-diagnostic services are clinically distinct or independent from the reason for the beneficiary’s admission) by reporting condition code 51 on the separately billed outpatient non-diagnostic services claim.

    Effective: June 25, 2010
    Implementation: April 4, 2011

  3. #3
    Join Date
    Apr 2007
    Jacksonville, FL (90417)

    Exclamation In the same boat, and it's a leaky one

    Our primary care practices and hospitalist group fall under the definition and I need some clarification on how it affects these physicians. I've read CMS' MLN Matters article MM7502 ( http://www.cms.gov/Outreach-and-Educ...ads/MM7502.pdf ) and under Payment Methodology it states -

    "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), and require that the modifier be appended to the entity’s preadmission diagnostic and admission-related nondiagnostic services, reported with HCPCS/CPT codes, which are subject to the 3-day payment window policy. The wholly owned or wholly operated entity will need to manage their billing processes to ensure that they bill for their physician services appropriately when a related inpatient admission has occurred."

    I need to know WHICH HCPCS/CPT codes are subject to the 3-day payment window policy?

    Can anyone shed some light?

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