Consolidated 72-hour billing rule prohibits successful linking of encounter dates

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    • Type: Logic/Intent/Data Elements
    • Resolution: Unresolved
    • Priority: Moderate
    • None
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      The consolidated 72-hour billing rule states that if a patient has an outpatient encounter 72-hours prior to admission and then is later admitted to the same facility, the hospital organization should combine the Medicare claims from the outpatient encounter and inpatient encounter into one combined Medicare claim to send to CMS. Since the claim from the outpatient visit and inpatient encounter are combined, the admission date on the claim is the start of the outpatient encounter, resulting in a mismatch.
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      The consolidated 72-hour billing rule states that if a patient has an outpatient encounter 72-hours prior to admission and then is later admitted to the same facility, the hospital organization should combine the Medicare claims from the outpatient encounter and inpatient encounter into one combined Medicare claim to send to CMS. Since the claim from the outpatient visit and inpatient encounter are combined, the admission date on the claim is the start of the outpatient encounter, resulting in a mismatch.
    • Requesting the consolidated billing rule is acknowledged in the measure specifications to address this conflict.

      The consolidated 72-hour billing rule states that if a patient has an outpatient encounter 72-hours prior to admission and then is later admitted to the same facility, the hospital organization should combine the Medicare claims from the outpatient encounter and inpatient encounter into one combined Medicare claim to send to CMS. Since the claim from the outpatient visit and inpatient encounter are combined, the admission date on the claim is the start of the outpatient encounter, resulting in a mismatch. 

            Assignee:
            Michael Cocchiola (Inactive)
            Reporter:
            Kristen Zuchegno
            Votes:
            2 Vote for this issue
            Watchers:
            6 Start watching this issue

              Created:
              Updated: