Outpatient to Inpatient 3-Day Window

Description

Preadmission and preoperative services are often necessary to ensure the health and safety of a member before they undergo surgery or inpatient admission. A wide range of examinations and diagnostics may be considered preadmission or preoperative services, including, but not limited to X-ray, laboratory tests and EKGs.

Centers for Medicare and Medicaid Services (CMS)⁠ “Three-day window” rule considers these related preadmission and preoperative services incidental to the subsequent facilities admission or surgical payment.

CMS “Three‐day window” definition:

“Defined as three (3) days prior to and including the date the beneficiary is admitted as an inpatient. For example, if a beneficiary is admitted as an inpatient on Wednesday, then Sunday, Monday, Tuesday or Wednesday is part of the three‐day window. Under the payment window policy, a hospital (or an entity that is wholly owned or wholly operated by the hospital) must include on the claim for a beneficiary's inpatient stay, the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient nondiagnostic services that are furnished to the beneficiary during the 3-day payment window.” (Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 90.7 and 90.7.1)

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. (Medicare Claims Processing Manual, Pub. 100-04, Chapter 3, Section 40.3)

This policy applies to facility claims. Please refer to global allowance rules in the Bundling Guidelines policy for professional claims.

Policy

Blue Cross Blue Shield Nebraska will limit reimbursement for preadmission and preoperative services according to the criteria outlined in this policy.

Reimbursement Guidelines

Place of Service

• Inpatient
  • Preadmission and preoperative services performed at the same hospital system with the same federal tax ID.
    • Within 72 hours – date of admission/surgery included
    • Not separately reimbursable, included in inpatient payment
• Outpatient
  • Preoperative services performed at the same facility
    • Within 72 hours – date of surgery included
    • Separately reimbursable when included on surgical claim 

Rationale

Based on CMS guidance, preadmission and preoperative services performed by the admitting hospital within seventy-two (72) hours of inpatient admission, including the date of admission, are deemed to be included in the subsequent inpatient admission payment.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive.

References

Medicare Claims Processing Manual, Global Surgery

Application

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore, member benefit language should be reviewed before applying the terms of this policy.

_{Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross Blue Shield Association.}