Medical Billing

# 72 Hour Rule Implementation in Medical Billing

- August 22, 2024
- Posted by Kristen Edwards

27 Sep

To combat fraud related to the False Claims Act, “the Centers for Medicare” and “Medicaid Services (CMS)” implemented the three-day rule, also known as the “72-hour rule”. This rule requires that all outpatient diagnostic or some other medical services delivered within 72 hours of hospital admission be bundled and billed collectively rather than individually. This can help prevent fraudsters from billing for services that were never provided.

## What is the “72 Hour Rule”?

The 72-hour rule is just one of many measures put in place by the CMS to help combat fraud and abuse within the healthcare system. Aside from this rule, the CMS requires that all claims for payment be submitted within a specific timeframe, that providers only bill for medically necessary services, and that providers keep accurate and complete medical records.

Providers can help ensure that they are billing correctly and not engaging in fraudulent activities by adhering to these rules and regulations. If you have any questions about the 72 hour rule or any other billing requirements, please contact your local CMS office.

### Services covered by the 72 Hour Rule

The “72 Hour Rule” covers diagnostic services such as:

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

## Inclusions and Exclusions in the Medicare “72 Hour Rule”

source:fiercehealthcare.com

### Inclusions

Here are some examples of what qualifies as inclusion under this new rule: blood pressure checkups, weight measurements, eye exams (including those related to glaucoma), urine tests (including those related to diabetes), electrocardiograms (ECGs), pulmonary function tests (PFTs), chest X-rays (CXRs), upper gastrointestinal series (UGIs), lower gastrointestinal series (LGIS), endoscopies, etc. All of these things must be billed together if they’re done within 72 hours of admission to the hospital; otherwise, it would be considered a false claim.

### Exclusions

On the other hand, some things don’t qualify as inclusions under this new rule: EKGs (unless they’re related to a heart condition or some other cardiovascular issue); EEGs; PET scans; CT scans; MRI scans; x-rays other than CXRs; blood work; pain medication prescriptions; etc. These things should be billed separately if done within 72 hours of admission to the hospital; otherwise, it would be considered a false claim.

### Why is the “72 Hour Rule” Made?

The reason behind the rule is that many times, patients admitted to the hospital do not receive all of their outpatient services during their stay. So, if these services are billed separately, it is difficult to tell whether or not they were rendered. However, when they are billed together, it is much easier to see if all of the services were performed.

### Where does the “72 Hour Rule” apply?

This rule applies to all Medicare providers, including hospitals, physicians, and other healthcare professionals. CMS has stated that it will closely monitor claims submitted in accordance with this new rule and will take appropriate action if any fraud is discovered.

### Record Keeping

When a patient is admitted to the hospital, the staff must keep accurate records. This is necessary so that Medicare can properly process and pay the medical bills. To meet Medicare’s requirements, each bill must include the following information:

- Diagnosis
- Complications and comorbidities (secondary diagnosis)
- Procedures performed
- Age of the patient
- Gender
- Discharge disposition

source:fiercehealthcare.com

### CAATs help Hospitals Comply with the 72-Hour Plan Medicare Rule

Many hospitals are struggling to comply with the 72-Hour Plan Medicare rule, which requires that all bills for Medicare patients be bundled together. To avoid penalties, some hospitals are turning to computer-assisted audit techniques (CAATs) to help spot separate bills that should be bundled. CAATs can help prevent mistakes and ensure compliance with the law.

### Why is it important to use?

The reason why compliance with the “72 hour rule” is so important is that it helps to prevent overbilling and fraud. Due to the complexity of the rule, it is quite simple to accidentally double-bill Medicare. To avoid overpaying for bills, CMS and the Office of Inspector General (OIG) closely monitor compliance. When providers violate the laws, they risk being subjected to interrogations and overpayment recovery, which could result in significant financial penalties for the services they provide.

### Takeaway

According to Medicare guidelines, certain services must be rendered within 72 hours for providers to be reimbursed. These services include inpatient hospital care, skilled nursing facility care, and home health care. The rule is designed to prevent providers from billing Medicare for services that were never actually performed. Don’t get caught out of pocket, know the rules!

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