Health Information Management

Follow 72-hour and 24-hour rules when billing an outpatient admitted after colonoscopy complications

APCs Insider, May 11, 2007

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QUESTION: A patient presents to our hospital for a colonoscopy as an outpatient. Our clinic provider performed the procedure in the hospital, and the patient returned home. Shortly afterwards, however, the patient developed complications. The next day, the patient returned to the hospital and staff had to admit him. How should the hospital bill these services?

ANSWER: Many managed-care contracts specify how to combine outpatient and inpatient claims in scenarios such as this one. It would not be possible to answer your question for these payers without the missing information. Since this question most often occurs with Medicare patients, we'll answer from that perspective.

All diagnostic and related non-diagnostic services within 72 hours prior to the date of the beneficiary's admission are deemed to be inpatient services and are included in the inpatient payment, as long as the beneficiary has Part A coverage. For more information, refer to the CMS Internet Only Manual (IOM); Publication 100-4; Chapter 3; Section 40.3.

What facility types require the 72-hour rule?

Acute care hospitals, which are paid under the inpatient prospective payment system, require this rule. This includes all outpatient departments that are provider-based, licensed, and are part of the acute-care hospital. These departments can be an on- or off-campus part of the main hospital.

What facility types require the 24-hour rule?

Long-term care hospitals, inpatient rehabilitation hospitals/units, psychiatric hospitals/units, and any hospital distinct part unit requires the rule.

Are any facility types exempt from these provisions?

Yes. Critical access hospitals are exempt from the 72/24 provisions. These hospitals must bill outpatient services prior to an admission, and report them on a separate bill from any inpatient services. Critical access hospitals must separately bill outpatient services rendered on the patient's date of admission, and these hospitals will receive separate payment for these outpatient services.

Should we file outpatient services on the inpatient claim when they are rendered within 72 hours of admission?

No. You may separately bill nondiagnostic services not related to the inpatient stay (defined as not having the same admitting diagnosis code). Examples include emergency room services, physical, occupational, and speech therapy. This is defined in the Medicare Claims Processing Manual, Chapter 3, Section 40.3.

Medicare rejected the inpatient claim for overlapping the outpatient claim. How do I get paid for the inpatient charges?

Cancel the outpatient claim. When the outpatient claim cancellation has finalized, resubmit the inpatient claim and include the diagnostic and related charges, as well as the ICD-9 codes of the outpatient claim. You can submit a separate outpatient claim, but only for nonrelated, nondiagnostic services.

Medicare rejected the outpatient claim for overlapping the inpatient claim. How do I get paid for the outpatient charges?

You'll need to adjust the inpatient claim. Use the appropriate adjustment reason code, D1 for change in charges. Also use the document control number of the inpatient claim, add the outpatient charges to the inpatient claim, and then submit the adjustment.

When the outpatient services are included on the inpatient bill, will the date of service change to include the outpatient date(s)?

No. Count the day on which the patient is formally admitted as an inpatient as the first inpatient day. Be sure to include all outpatient charges and ICD-9 procedure and diagnosis codes that encompass the outpatient services. The date of an outpatient procedure (e.g., a cardiac catheterization) can be before the date of the inpatient admission.

The Medicare Claims Processing Manual, Chapter 3, Section 40.3, contains a complete list of revenue codes that are considered diagnostic services and must be bundled into the inpatient claim. For this provision, diagnostic services are defined by the presence on the bill of the following revenue/HCPCS codes:

  • 0254: Drugs incident to other diagnostic services
  • 0255: Drugs incident to radiology
  • 030X: Laboratory
  • 031X: Laboratory pathological
  • 032X: Radiology diagnostic
  • 0341: Nuclear medicine, diagnostic
  • 035X: CT scan
  • 0371: Anesthesia incident to Radiology
  • 0372: Anesthesia incident to other diagnostic services
  • 040X: Other imaging services
  • 046X: Pulmonary function
  • 0471: Audiology diagnostic
  • 048X: Cardiology, with HCPCS codes 93015, 93307, 93308, 93320, 93501, 93503, 93505, 93510, 93526, 93541, 93542, 93543, 93544 - 93552, 93561, or 93562
  • 053X: Osteopathic services
  • 061X: MRT
  • 062X: Medical/surgical supplies, incident to radiology or other diagnostic services
  • 073X: EKG/ECG
  • 074X: EEG
  • 092X: Other diagnostic services

Note that you can separately bill charges on an outpatient claim that are under other revenue codes from those listed above and are not related to the admission (i.e., do not have the same diagnosis code).



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