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Understand the Medicare three-day payment window for recurring accounts

APCs Weekly Monitor, June 29, 2007

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QUESTION: Regarding the May 11, 2007, APCs Weekly Monitor ("Follow 72-hour and 24-hour rules when billing an outpatient admitted after colonoscopy complications"), we have a question about how to get around those recurring (cycle) accounts. These accounts occur when the patient ends up having either a procedure performed in the middle of this cycle, presents for a radiology visit, or ends up in the acute-care facility as an inpatient.

We have several outpatient departments in our hospital (e.g., wound center, infusion center). We use revenue code 510 to bill services performed in these centers. From what we understand, we have to move those charges to the inpatient claim or the radiology services to the cycle account, depending on the circumstances. We can't use occurrence span code 74 when revenue 510 is involved on the recurring account. This is very difficult to keep up with, and it causes us delays.

Is there another way around all this moving of charges? 

ANSWER: Regarding the Medicare three-day payment window, you only have to bundle diagnostic services or related non-diagnostic services into an inpatient admission. For hospitals subject to the IPPS, the time period to bundle these services is three days prior to admission. For hospitals excluded from IPPS, the required bundling period is one day prior to admission.

Charges billed under revenue codes 254, 255, 30x, 31x, 32x, 341, 35x, 371, 372, 40x, 46x, 471, 481 (with HCPCS codes 93015, 93307, 93308, 93320, 93501, 93503, 93505, 93510, 93526, 93541, 93542, 93543, 93544--93552, 93561, or 93562), 53x, 61x, 62x, 73x, 74x, and 92x are considered to be diagnostic services. Bundle them into the inpatient admission regardless of whether they are related to the inpatient admission.

You are not required to bundle non-diagnostic outpatient services that are unrelated to the inpatient stay (meaning that all the digits of the ICD-9-CM principal diagnosis code of both the inpatient and the outpatient services claim are not an exact match). Hospitals may bill these services separately. 

Consider this example:

A hospital reports outpatient clinic charges with dates of service on June 4, 6, 8, 13, 15, including charges for infusion services (revenue code 510), and pharmacy services (revenue code 636) with ICD-9-CM diagnosis code 682.5. The hospital also submits a hospital inpatient claim for the same patient from June 9-11, with a diagnosis of 428.0.

In this case, bill the outpatient clinic charges separately from the inpatient claim. Report an occurrence span code of 74 showing the inpatient "from" and "to" dates.

When a radiology visit for a chest x-ray occurs between visits to the outpatient clinic (i.e., on a different date), you may submit the radiology bill separately. You may also bill it on the claim with the infusion/pharmacy services. If the date of service for the radiology exam is the same date as an infusion service at the outpatient clinic, combine the radiology and infusion services on the same claim.

For detailed information on this subject, read the Medicare Claims Processing Manual (100-04), chapter 3, section 40.3: http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf.

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