The 72-Hour Rule and Medicare: What You Need to Know

If you are a hospital administrator, you should know about Medicare’s 72-hour rule.  The 72-hour rule treats outpatient services the same as inpatient services.  The rule states that all services provided for Medicare patients within 72 hours of the hospital admission are considered to be part of the inpatient services and are to be billed on one claim.

The 72-hour rule is part of Medicare’s Prospective Payment System (PPS).  Under the PPS, Medicare pays hospitals a pre-determined rate for each hospital admission.  Clinical information is used to classify each patient into a Diagnosis Related Group (DRG).  Such information includes the principal diagnosis, complications and co-morbidities, surgical procedures, age, gender, and discharge disposition of the patient.  It is very important for hospital personnel to properly code the diagnoses and procedures, since that information is what determines what DRG Medicare assigns to the patient.  Incorrectly coded diagnoses and dramatically effect reimbursement, as rates are determined by the DRG.

Medicare pays the hospital a flat rate for each DRG, regardless of what services were actually provided.  Under this rule rule, payments for any diagnostic services provided within three days prior to hospital admission are considered covered by the DRG payment, even if they are unrelated to the admission.  Other services are only covered if they are related to the reason for admission. Diagnostic services covered under the PPS include but are not limited to laboratory work, radiology, nuclear medicine, CT scans, anesthesia, imaging services, cardiology, osteopathic services, EKG’s, and EEG’s.  Non-diagnostic services such as physical and speech therapy that are not related to the inpatient stay may be filed separately.

Acute care hospitals require the 72-hour rule.  Other facilities require the 24-hour rule, such as long-term care hospitals, rehab hospitals, and psychiatric hospitals.  Critical access hospitals are excluded from the 72-hour/24-hour provision.  As an administrator of a hospital covered under the 72-hour rule, you will need to make sure that hospital billing personnel properly code the patient information in order to ensure that Medicare pays for the correct DRG, and also that all services within 72 hours of the hospital stay are being billed on one claim.  Improper coding and billing can cause unnecessary hassles

26 Responses to The 72-Hour Rule and Medicare: What You Need to Know

  • Catherine Egan says:

    Can you help me apply this 72 hour rule correctly. My inpatient admission is DRG 121. Patient had an acute subendocardial MI as well as many secondary comorbidities one of which is ESRD, the patient is on dialysis maintenance. My outpatient encounter which occurred previous to admission but within the 72 hours was for a complication of the dialysis catheter requiring angioplasty.

    My question is-Should this be combined on one claim and regrouped to the new DRG to include the angioplasty procedure? OR these are not considered diagnostic procedures so this rule would not apply OR These conditions are not related to each other and this rule would not apply?

    Your help is greatly appreciated,
    Cathy Egan

  • ANGELA MOUZON says:

    With a recur acct (therapy): If you have a op surgery acct for example 03/06/2009 and the pt also had therapy on the recur acct for 03/06/2009 how do you bill?

    Do you put a 74 span code on the therapy acct along with dos and bill both accts separately?

  • Teresa Feliz says:

    what if it is an ER visit and the provider is stating the diagnosis was different than the admit diagnosis? they are stating medicare would pay each and it would not fall under 72hr rule

  • becky says:

    when billing recurring account that has a sx acct on one of the therapy days, you can bill seperately. Add G0 condition code and add span 74 on the recurrng account with date of sx.

  • Carolyn says:

    If a pateint is discharged to home from in-patient hospital and then desides that they need home health services within 3 days of discharge how would that get coded, also since we wont have the discharge status to hhs and there are no Dr’s orders in file who would change the discharge status so medicare will pay.Thank you
    I know that I saw a policy on the 72 hour rule but have been unable to locate it anywhere

  • Kathy COOk says:

    If the pt comes into the ER and this results in an inpatient admission, should you always combine the ER visit with the inpatient admission? Note we have ER physicians that do not admit to our facility so this would always be a different MD admitting the patient from the ER.

  • Glenn says:

    How many days or hours must a patient have between IP discharge and re-admission for the same medical conditon before the provider may bill two DRG’s. Example if the patient is discharged on 01/01 1300hrs and readmited on 01/03 0300 hrs with the same primary DX, can the provider bill two DRG’s or should the claims be combined. What is the CMS publication and chapter?

  • Jason H. says:

    What if the patient had no medicare/medicaid coverage prior to the 72 hours of the admitt. The admit date was also the patients effective date, would the prior 72 hour visit still be covered with the admit visit.

  • Carolyn says:

    IF a pt is on “acute dialysis” w possible return of function, if he leaves the hospital, who pays for the acute episode of dialysis. Is the hospital responsible to pay? Can they be reimbursed by Medicare if they have to contract to a local OP facility for the treatments for the next 3 months?

  • Ashley says:

    I was wondering if a patient came in for a diagnostic cystoscopy and during this procedure the patient goes in to V-fib. At this point CPR is started, and subsequently the patient is admitted as an inpatient. Would I combine the outpatient to the inpatient account or split them since the CPR was done?
    Thank you,

    Ashley

  • Terry says:

    Does the 72 hour rule include diagnostic tests performed 4-5 days prior to hospital inpatient admission?

  • Pamela C McLain says:

    When my outpatient visit is not related to the inpatient visit, is there anything I need to add to the inpatient visit for Medicare to pay it? Example, a condition code or occurence code? I don’t want my inpatient visit to deny.

  • Kevin says:

    If a hospital patient is discharged and starts radiation at a free standing facility withing 72 hours of being discharged – can the facility get paid for the services provided within that 72 hour window?

  • Sharon Scruggs says:

    I have the same question as Glenn on March 4th, 2010. Your number 5. Which states: How many days or hours must a patient have between IP discharge and readmission fo the same medical condition before the provider may bill two seperate claims. Example: pt discharge on 1/1 radmitted with same diagnosis on 1/3 same DRG.

  • Louise Williams says:

    Please explain the 72hr Medicare Guideline if the patient had pre-op charges on the bill and within 72hrs is admitted for procedure ,can those pre-op charges remain on the same account with the procedure account ?
    Example:Patient had Lab Work and X-Rays on 12/10/10 and admitted into hospital for procedure on 12/13/10 Can those charges remain on one account the Surgery acct.?

  • Karen Beaubien says:

    I was wondering, how many days or hours must a patient have between IP discharge and re-admission for the same medical conditon before the provider may bill two DRG’s. Example if the patient is discharged on 01/01 1300hrs and readmited on 01/03 0300 hrs with the same primary DX, can the provider bill two DRG’s or should the claims be combined. What is the CMS publication and chapter?

  • Gina says:

    How does this affect the provider. In other words, does the provider only use one code or is this only geared to the hospital?

  • Terri Richmond-Holt says:

    How many days or hours must a patient have between IP discharge and re-admission for the same medical conditon before the provider may bill two DRG’s. Example if the patient is discharged on 01/01 1300hrs and readmited on 01/03 0300 hrs with the same primary DX, can the provider bill two DRG’s or should the claims be combined. What is the CMS publication and chapter?

  • Lucinda Roberts says:

    72 hour rule for CMS
    Outpatient services are rendered (medications, blood transfusions, lab work, etc) then the patient is scheduled for admittion within 72 hours for inpatient bone marrow transplant. Does the 72 hour rule apply?

  • Nancy Gamble, CPC says:

    When you have a Patient that is coming in for Observation Antepartum care and returns for either Inpatient Delivery or PostPartum Care and the antepartum is related how do you combine the codes? Would you make all codes as delivered or postpartum or include the antepartum codes and ignore the edit?

    Thanks!

  • GLORIA OPEIL says:

    If a patient had cataract surgery and ultimately gets admitted for atrial fibrillation whic is not related to surgery can surgery be billed seperately

  • Rose says:

    I had a patient that was seen in the ER on 6/25 and was a observation patient for 2 day then was admitted as a inpatient on 6/27. Should the from and too dates on the UB be 6/25 through 6/27 or should the date be 6/27 through 6/27

  • VENESSA R. says:

    HOW DOES THE 72 HR RULE APPLY TO PHYSICIAN CHARGES?
    THE HOSPITAL IS A CRITICAL ACCESS FACILITY, BUT HOW CAN I BUNDLE OR GROUP CHARGES WHEN THE PATIENT IS UNDER OBSERVATION THE FIRST DAY OR TWO, THEN BECOMES INPATIENT? CAN I BILL FOR THE FIRST TWO DAYS OF OBSERVATION AS WELL AS THE INPATIENT STAY?

  • LINDA MCCRADY says:

    Does the receiving hospital have to pay for the ambulance transport from one hospital to another if within 72 hours?

  • Stephanie C. says:

    My question is not directly related to billing, but I was wondering if the clinical process needs to be started over of the patient leaves the facility for more than 72 hours.

  • Kathy says:

    Physicians are employed by hospital – can you bill separately for their services – reading of nuclear stress tests, ekgs, etc with this change and also billing for their services?

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