Coding Notes
Three-Day Window Updates
By Gail Garrett, RHIT
THE PRESERVATION OF Access to Care for Medicare Benefi- ciaries and Pension Relief Act of 2010 was signed into law on June 25, 2010. One of its provisions revised the three-day pay- ment policy, or the so-called “three-day DRG window.” This article highlights the changes to the three-day window payment policy. Three-Day Window Updates Effective June 25, 2010, all short-term, inpatient acute care fa- cilities reimbursed under the Medicare Inpatient Prospective Payment System (IPPS) are subject to the three-day payment rule. Those facilities exempt from the IPPS (e.g., long-term care
hospitals, inpatient rehabilitation hospitals and units, facilities,
psychiatric hospitals and units) are subject to a one-day window. Critical access hospitals are not subject to the one- or
three-day payment window.
Under the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, when outpatient services
are provided by the hospital (or an entity wholly owned or operated by the hospital) within the three-day payment window,
diagnostic services are included on the inpatient claim. In other
words, the new law made no changes to the Centers for Medicare and Medicaid Services’ (CMS) long-standing policy regarding the billing of diagnostic services. These services are still required to be bundled into the DRG payment when performed
within the payment window.
Take for example a patient who is admitted as an inpatient on
a Thursday. The diagnostic services provided by the hospital on
Monday, Tuesday, Wednesday, or Thursday should be reported
Three-Day Payment Window Background
PRIOR TO JUNE 25, 2010, hospitals were required to bundle
all outpatient diagnostic services furnished to a Medicare
patient on the date of a beneficiary’s admission or during the
three days preceding the inpatient hospital admission into
the inpatient encounter.
On the other hand, outpatient nondiagnostic services provided during the payment window were to be included on
the bill for the patient’s inpatient stay at the hospital only
when the services were “related” to the beneficiary’s admission.
The term related was defined as an exact match of all five
digits of the Medicare patient’s diagnosis code in the outpatient encounter when compared to the inpatient hospital
principal diagnosis code.
on the inpatient claim.
CMS’s Claims Processing Manual identifies diagnostic services by the presence on the bill of the revenue or CP T codes in the
table at right.
The provision for nondiagnostic (therapeutic) services was
revised under the new law. Nondiagnostic/therapeutic services
are included on inpatient claims if they are provided on the day
of admission or are clinically associated with the reason for the
patient’s inpatient admission and occur within the payment
window.
Under the new statute the term “other services related to the
