72 hour rule

[LPurcell · Accepted solution]

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LR wrote:

If a hospital owns a Provider Based practice does the medicare 72 hour rule apply to diagnostic services provided in that practice.  I could not find info on this on the CMS website.

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Any diagnostic service billed on a UB-04, including that provided in a provider based clinic would be included.  It would not include any professional physician services that are billed on a CMS-1500 claim. A therapeutic service (eg clinic visit) would be included only if the principal diagnosis on the outpatient claim matches the principal diagnosis on the inpatient claim.

The regulation is from the Medical Claims Processing Manual, Chapter 3, Section 40.3.B:

"Diagnostic services (including clinical diagnostic laboratory tests) provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment, unless there is no Part A coverage. For example, if a patient is admitted on a Wednesday, outpatient services provided by the hospital on Sunday, Monday, Tuesday, or Wednesday are included in the inpatient Part A payment."

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Disclaimer: All responses intended for internal guidance only and not as a recommendation for a specific situation. Readers should consult an official source (AHA, AMA, etc.) or a qualified attorney for specific legal guidance.