Importance of Medicare 72 Hour Rule

The Centers for Medicare & Medicaid Services (CMS) provisions a three-day rule also called 72‐hour rule to crack down on frauds as a part of the False Claims Act. 

Under the 72 hour rule any outpatient diagnostic or other medical services performed within 72 hours before being admitted to the hospital must be combined and billed together and not separately. Some examples of diagnostic services that are covered in this rule include lab work, radiology, nuclear medicine, CT scans, anesthesia, cardiology, osteopathic services, EKG, and EEG.

What is the 72 hour rule?

If a patient is admitted to the hospital and avails diagnostic services within even three days before being admitted to the hospital then these services are considered inpatient services and are included in the inpatient payment, i.e. bundled. This rule applies to every diagnostic test or other services conducted in the concerned hospital within three days prior to the patient’s admission. Diagnostic services that are covered in the 72 Hour Rule include: 

• Lab work
• Radiology
• Nuclear medicine
• CT scans
• Anesthesia
• Cardiology
• Osteopathic services
• EKG
• EEG

Unrelated Diagnostic Services are bundled with in-patient services in certain conditions

Under the 72 hour rule unrelated outpatient services can be bundled with the inpatient surgery in certain cases. It can be understood better with the help of the following example. 

There is a patient who goes to the hospital’s outpatient center for an x-ray of her leg. Usually this is billed as an individual service and on its own separate from other claims. However, if the same patient is admitted to the hospital within 72 hours for a previously scheduled inpatient surgery, then the leg x-ray is billed together with the surgery. The surgery doesn’t even have to be on her leg. It could be a completely unrelated procedure, like a surgery on her hand. The important point here though is that the outpatient service, which in this case is the x-ray on her leg, was a diagnostic service.

However, it is important to notice that in case the outpatient service is not a diagnostic service then it can be billed separately. In the example stated above, if instead of the x-ray the service provided to the patient was a physical therapy session which is not a diagnostic service, then the physical therapy service would be billed separately.

Why is compliance with the 72 hour rule important?

With so much to know about the 72 hour rule, it’s very easy to mistakenly double-bill Medicare. CMS and the Office of Inspector General (OIG) keep a strict check on compliance of the 72 hour rule to prevent frauds and overpayment for bills. Providers may face investigations and overpayment recoveries and they may also lose out on important payments for the services provided.

To reduce the risk of overpayments and underpayments, hospitals must ensure that every person involved in the coding and billing process should be educated on the rule. The best way is to make a policy that dictates the details of procedures that are followed to comply