Corporate Compliance

Note from Hugh

Medicare Insider, February 5, 2008

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As discussed below, last week CMS announced that it is revising its manual instructions on the three day payment window (often erroneously called the "72 hour rule") effective July 1. As a result of these revisions (particularly the second change discussed below) most hospitals will need to make systems/process changes relating to how they handle claims for outpatient services furnished prior to an inpatient admission. In general, there are two changes:

First, in the past, the fiscal intermediaries (FIs) were instructed to use the "statement covers through date" to determine whether outpatient services fell within the payment window. Under the revised instructions, the FIs are to apply the three day window to each line item on the outpatient claim based on the line item date of service billed. This could potentially affect the processing of outpatient claims for services furnished prior to an inpatient admission when the outpatient claim spans more than one date of service.

Second, CMS has revised the list of revenue codes (and revenue/CPT code combinations) that are considered to represent "diagnostic" services for purposes of applying the three day payment window.



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