New Condition Code to Bypass 3-Day Window Edit for Non-Related Therapeutic Services
on Wednesday, 17 November 2010. All News Items
Transmittal 796 (CR7142) clarifies the payment window for outpatient services treated as inpatient services by adding a new condition code to report when non-diagnostic (therapeutic) services are not related to the inpatient admission. Starting April 1, 2011, providers may add condition code 51 (Attestation of Unrelated Outpatient Non-diagnostic Services) for services on and after June 25, 2010 that they determine to be unrelated to the reason for admission.
The transmittal does not provide much (if any) additional guidance on how to determine if services are related or not – the definition of unrelated in the transmittal is “clinically distinct or independent from the reason for the beneficiary’s admission.” In previous comments, CMS has maintained that the determination of related versus unrelated is to be made by the hospital and the use of condition code 51 is the hospital’s attestation that the services are unrelated.
Other points from the article include:
- Ambulance and renal dialysis maintenance services are exempt from the payment window rule - (that is, they do not have to be combined with the inpatient admission).
- All services provided the day of admission (except ambulance and dialysis services) must be combined to the inpatient claim for all types of hospitals.
- The payment window is 3 calendar days for IPPS hospitals (first, second and third calendar day preceding the admission) and 1 calendar day for non-IPPS hospitals.
- All diagnostic services provided within the payment window must be combined to the inpatient claim. (See section 40.3 (B) of Chapter 3 of the Medicare Claims Processing Manual (Pub 100-04) for a list of diagnostic revenue codes and HCPCS codes.)
- Outpatient non-diagnostic services provided within the payment window are deemed related and must be combined unless the hospital determines and attests that the services are not related to the reason for the patient’s admission. This applies to all types of therapeutic services (other than ambulance and dialysis services) including outpatient physical, occupational and speech therapy.
- A hospital must include on the claim for a beneficiary’s inpatient stay, the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient non-diagnostic services provided during the payment window.
- The payment window applies to the hospital and all entities that are wholly owned or wholly operated by the hospital.
Outpatient claims with a date of service on or after June 25, 2010, that did not contain condition code 51 received prior to April, 1, 2011, will need to be adjusted by the provider if they were rejected by FISS or CWF.For more information, read the CMS Transmittal at the link above or MLN Matters Article MM7142.