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July 7, 2010

Changes to Medicare "72-Hour Rule"

On June 25, 2010, the Preservation of Access to Care for Medicare Beneficiaries Act ("Act") was passed, which included changes to the Medicare "72-hour rule," also called the "3-day window" rule.  

The Medicare "72-hour rule" requires certain outpatient medical services that are performed during the 72 hours preceding a hospital inpatient admission to be bundled into one inpatient claim to Medicare.  All diagnostic services performed by the hospital, or by an entity wholly owned or operated by the hospital, and all therapeutic services that are related to the admission must be bundled. 

The Act includes clarification of the term "other services related to admission."  The term  includes "all services that are not diagnostic services (other than ambulance and maintenance renal dialysis services)" for which payment may be made by Medicare that are provided by a hospital (or an entity wholly owned or operated by a hospital) to a patient: (1) on the date of the patient's inpatient admission, or (2) during the 3 days (or in the case of a hospital that is not a PPS hospital, during the 1 day) immediately preceding the date of admission unless "the hospital demonstrates (in a form and manner, and at a time, specified by the Secretary) that such services are not related to such admission." Instructions from the Centers for Medicare & Medicaid Services (CMS) regarding the billing method for related therapeutic services are forthcoming. However, until such instructions are issued, for services provided after June 25, 2010, hospitals are instructed to include all diagnostic and non-diagnostic services that it believes are associated with the hospital admission on the inpatient claim.  The statute makes no changes to the billing of diagnostic services.

With respect to services provided prior to June 25, 2010, hospitals may continue to submit separate claims for therapeutic services that were unrelated to the inpatient stay, provided that the hospital has not already submitted a bill for such services, and provided further that the hospital has documentation to support the distinct nature of these services.   Importantly, the Act prohibits CMS from reopening or adjusting an inpatient claim, or otherwise paying a hospital "pursuant to any request for payment ... submitted ... for purposes of treating [services furnished in the 3-day window] as unrelated to a patient's inpatient admission ..."  Therefore, for these types of services, no adjustment of previously submitted inpatient claims is permitted on or after June 25, 2010.  For hospitals undertaking a retrospective review of services provided within the 72-hour timeframe, this new provision ends the ability of hospitals to unbundle and separately re-bill for therapeutic services that were originally bundled with the inpatient stay.

If you have any questions regarding this rule change, please contact:

 
 
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This publication is intended for general information purposes only and does not and is not intended to constitute legal advice. The reader must consult with legal counsel to determine how laws or decisions discussed herein apply to the reader's specific circumstances.  
 
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