Three-Day Payment Window: Information from Hospital Open Door Forum

on Wednesday, 08 September 2010. All News Items

CMS representatives addressed several questions regarding the Three-Day Payment Window during the August 26, 2010 Hospital Open Door Forum (ODF).

There is an issue with billing for procedures that occur prior to the date of admission but are included on the inpatient claim due to the 3-day payment window.  The date associated with the ICD-9-CM procedure code is prior to the admit date/from date on the claim and is causing a claim processing problem.  On the ODF, CMS instructed providers, for now, to change the date of the procedure to be the same as the admit date.  Providers should use the correct date of admission on the claim.  Providers expressed concerns about this guidance relating to inpatient-only procedures and RAC reviews.  CMS expects to be releasing a CR soon to address this issue.

CMS verified that the only repetitive services that are excluded from the 3-day payment window are ambulance and dialysis services.  Therapy services (PT, OT, and ST) are included in the 3-day payment window.

Providers are seeking further guidance on the definition of “not related.”  CMS did not commit to when further guidance would be available, but did state the assumption is that all services are considered related unless the medical record clearly demonstrates the service is clinically unrelated.  For example, admission for a complication from outpatient surgery would be considered related to the outpatient surgery if it occurred within the 3-day window.  The determination as to whether or not services are related must be made by the hospital, but are subject to review.

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