Further CMS Clarification Regarding 3-Day Payment Window Billing

on Thursday, 09 September 2010. All News Items

Earlier this week, MMP, Inc. released an e-mail blast with information from the August 26 Hospital Open Door Forum (ODF) concerning the 3-day payment window.  During the ODF, CMS representatives instructed hospitals to change the date of service on outpatient ICD-9-CM procedure codes bundled under the 3-day payment window rules to be the same as the inpatient admit date.  This answer from CMS was in response to questions from providers indicating claims would not process with an ICD-9-CM procedure code date prior to the admit/from date.  Today, CMS released the following notice clarifying that there are no claim processing issues related to the procedure date being prior to the admit/from date on the inpatient claim.  Providers should submit claims with accurate procedure dates and admit dates.

The link to the memorandum referenced in the notice is:

Here is the complete CMS notice:

Medicare’s 3-Day/1-Day Payment Window Policy: Outpatient Services Treated as Inpatient

During the Hospital Open Door Forum call on August 26th, 2010, hospitals expressed concerns regarding billing for procedures performed in the outpatient setting that must be bundled on the inpatient hospital bill in order to comply with the 3-day (or 1-day) payment window policy.  CMS recently issued a memorandum to providers regarding a statutory change in the policy pertaining to admission-related outpatient non-diagnostic services (http://www.cms.gov/AcuteInpatientPPS/Downloads/JSMTDL-10382%20ATTACHMENT.pdf).  Some hospitals were concerned that the Medicare claims processing systems may have edits that do not allow hospitals to bill the ICD-9-CM procedure code dates correctly for outpatient non-diagnostic services provided during the 3 calendar days (or 1 calendar day) immediately preceding the admission date on the inpatient claim. 

CMS has verified that the Medicare claims processing system does allow the ICD-9-CM procedure code dates for non-diagnostic services provided up to 3 calendar days prior to the admission date on the inpatient claim.  Therefore, hospitals are able to bill correctly for admission-related outpatient non-diagnostic services (that is, bundle the services on the inpatient hospital claim) without modifying dates on the inpatient claim.   The CMS foresees no system issues that prevent hospitals from billing  appropriately according to the 3-day (or 1-day) payment window policy.  If providers encounter systems difficulties, they should contact their local contractor, CMS Regional Office, or CMS Central Office, accordingly.

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