72 HOUR WINDOW IV

1. 72 HOUR WINDOW IV Medicare and Medicaid 3 Day Window Rule

2. GA MEDICAID 3 DAY WINDOW • The GA Medicaid 3 day window rule differs from the Medicare rule. • The 3 days encompasses both the 3 days prior to an Inpatient admission and the 3 days after an Inpatient discharge.

3. GA MEDICAID AND THE CMOs • The original “3 Day Rule” in the “traditional” Medicaid manual is also adhered to by the new GA Medicaid CMOs. • Wellcare • Amerigroup • Peachstate

4. GA MEDICAID AND THE CMOs • The GA CMOs are held to the original rules of traditional Medicaid in most cases. • You will need to review your CMO contracts to determine if your facility has negotiated an exception to the 3 day rule. • If no exception is noted then the rule will apply for both Medicaid and the CMOs.

5. MEDICAID MANUAL 904 • “Readmission for the same or related problem within three (3) days of admission or discharge is considered the same admission”

6. UNDERSTANDING THE RULE • To try and understand the rule you have to understand the DRG methodology. • Both Medicare and Medicaid pay using DRGs or Diagnostic Related Groups. • A DRG is a number assigned to a patient’s overall diagnosis for an inpatient admission.

7. UNDERSTANDING THE RULE • A patient is seen in the Emergency Room for bronchitis and is treated with outpatient antibiotics. Their condition worsens leading to an inpatient admission. • Both Medicare and Medicaid reason that because the treatment is related to the inpatient diagnosis, it should all be paid in one payment, the DRG payment.

8. MEDICAID GUIDELINES • Let’s review the Medicaid guidelines and rules by themselves and then we will compare differences between Medicare and Medicaid.

9. MEDICAID GUIDELINES • Medicaid makes no distinction between diagnostic and non-diagnostic charges. • The combining of Medicaid accounts is based more on clinical decision making then on actual diagnosis codes.

10. MEDICAID GUIDELINES • Medicaid wants outpatient accounts combined with inpatient accounts if “the patient has the same or related problem”. • Since a determination has to be made related to the patients “problem” or diagnosis, it is good practice to involve your Case Management or Medical Records department in your decision to combine accounts.

11. MEDICAID GUIDELINES • Some admissions may not seem to be related to outpatient accounts when looked at by a non-clinical person. However when the record is reviewed by a clinical practitioner, they may be able to see a relationship between the two accounts.

12. EXAMPLE • A patient is seen in the Emergency Room following a fall at home. The patient reports becoming dizzy and falling in the bathroom. The ER physician evaluates the patient for a minor head injury. A CT scan of the head is done along with labs and an EKG. The patient is feeling much better and is discharged home with instructions to follow up with their regular physician.

13. EXAMPLE • Two days later that same patient is admitted to the hospital as an inpatient. The patient has had a myocardial infarction or heart attack. The physician finds that the patient has a very low heart rate and a pacemaker is inserted.

14. EXAMPLE • On the surface it really doesn’t look like these two visits are related. • A closer look by a clinician may determine that the patient became dizzy and fell because of their low heart rate and that’s why they were seen in the emergency room two days prior to the inpatient admission.

15. EXAMPLE • According to the Medicaid rules since the two visits were related to the same problem the account would need to be combined for billing and only one payment would be made.

16. MEDICAID GUIDELINES • Once the determination is made that the two visits are related, the combining of the accounts is very straight forward. • If a visit is related and needs to be combined all charges from the outpatient account are combined with the inpatient account for billing.

17. MEDICAID GUIDELINES • Medicaid also includes outpatient visits that occur after an inpatient discharge in their 3 Day Window rule.

18. PROCESS • With Medicaid including the three days prior to an inpatient admission and the three days after an inpatient discharge in their rule, it may create some problems for hospital processes that attempt to catch and hold processing of accounts until their relationship for combining is determined.

19. PROCESS • With Medicaid patients you will need to be very careful in your registration process to determine if a patient has been in your facility with in the past three days. • You must ask not only about prior outpatient visits but about inpatient discharges as well.

20. There are times when your physicians may want to schedule an outpatient visit or surgery on a patient that they are sending home from an inpatient stay. The outpatient procedure may be scheduled within three days of the inpatient discharge. If the patient returns in that 3 day window, remember that you will have to combine that visit with the inpatient account if they are related in any way.

21. Sometimes the outpatient testing must be done within that three day window. An example would be a newborn that has some mild newborn jaundice and must return within 48 hours of their discharge for a bilirubin recheck. The bilirubin testing would need to be combined with the inpatient newborn account for billing as the birth with jaundice is related to the bilirubin testing for newborn jaundice.

22. REVIEW Let’s review briefly all of the material that has been included in parts I-IV of this class. After we review we’ll do just a few more practice examples to increase our understanding of both the Medicare and Medicaid 3 Day Window rules.

23. MEDICARE RULE PART I • If a Medicare patient is seen in your facility as an outpatient within 3 days of an inpatient admission and the principal diagnoses do not match to the last digit, only combine the outpatient diagnostic charges with the inpatient bill. • You can still bill the non-diagnostic outpatient services separate from the inpatient account.

24. MEDICARE RULE PART II • If a Medicare patient is seen in your facility as an outpatient within 3 days of an inpatient admission and the principal diagnoses match exactly, ALL of the charges, diagnostic and non-diagnostic, from the outpatient account should be combined with the inpatient bill. • Remember to have your coding staff combine and re-sequence the diagnosis codes if necessary.

25. MEDICAID RULE • An outpatient visit, occurring 3 days before an inpatient admission or within 3 days of an inpatient discharge, that is related to the inpatient diagnosis or problem must be combined completely with the inpatient account for billing.

26. PRACTICE #1 • On November 3, 2006 Medicare patient Mrs. Whitmire receives non-diagnostic services at Hospital A. Her principal outpatient diagnosis is 365.2. • On November 5, 2006 Mrs. Whitmore is admitted as an inpatient at Hospital A with a principal diagnosis of 365.2.

27. PRACTICE #1 • Should the non-diagnostic services on the outpatient account be combined with the inpatient account for billing?

28. PRACTICE #1 • Yes! The non-diagnostic charges should be combined with the inpatient bill because the service was within the 3 day payment window and the principal diagnoses on both accounts were an exact match.

29. PRACTICE #2 • On April 7, 2006 Medicare patient Ms. Meeks is seen at Hospital A for physical therapy services related to chronic back pain. • On April 9, 2006 Ms. Meeks is admitted as an inpatient to Hospital A with appendicitis.

30. PRACTICE #2 • Should the outpatient physical therapy charges be combined with the inpatient account for billing?

31. PRACTICE #2 • No! Physical Therapy services are non-diagnostic. The diagnoses on the accounts were completely different. No charges would be combined and you would bill the two accounts separately.

32. PRACTICE # 3 • Mr. Lewis a Medicare patient is seen at Hospital A on May 5, 2006 to have lab work done for his yearly physical exam. • Mr. Lewis returns to Hospital A the next day after a car accident and is admitted as an inpatient for a ruptured spleen.

33. PRACTICE # 3 • Should the lab work from Mr. Lewis’ annual physical be combined with his inpatient auto accident account?

34. PRACTICE # 3 • Yes! The lab work was done at the same hospital that Mr. Lewis was admitted to the next day and lab work is considered diagnostic. Even though the diagnoses are unrelated, you always combine diagnostic charges with an inpatient account if it falls within the Medicare 3 day payment window.

35. PRACTICE # 4 • Alexa is a Medicaid patient seen in the emergency room for fever and cough on May 8, 2006. The ER doctor gives her a diagnosis of bronchitis and discharges her home with a prescription. • On May 9, 2006 Alexa is worse and is admitted to the same hospital as an inpatient with a diagnosis of pneumonia.

36. PRACTICE # 4 • Alexa is discharged home on May 12, 2006. • May 14, 2006 Alexa returns to the same hospital for a follow up chest x-ray. • This patient now has 3 accounts.

37. PRACTICE # 4 • Should either of the outpatient accounts be combined with the inpatient account for billing. If yes, which ones and why?

38. PRACTICE # 4 • Since Alexa is a Medicaid patient the 3 day payment rule includes the 3 days before admission and the 3 days after discharge. • Both outpatient accounts are related to the inpatient admission of pneumonia. • All charges on both outpatient accounts should be combined with the inpatient account for billing.

39. A FINAL WORD

40. Contact Information Sandy Sage R.N. Sandy.Sage@HCAhealthcare.com