DEPARTMENT: Health Information
Management Services
PAGE: 1 of 5
EFFECTIVE DATE: May 31, 2004
POLICY DESCRIPTION: Outpatient Services and
Medicare Three Day Window
REPLACES POLICY DATED: 4/3/98; 8/1/00;
6/1/02
REFERENCE NUMBER: HIM.GEN.001
SCOPE: All personnel responsible for performing, supervising or monitoring coding of services that
meet Medicare’s Three Day Window criteria, including, but not limited to, the following
departments:
Admitting/Registration
Resource Management
Ethics & Compliance Officers
Patient Accounting/Business Office
Health Information Management Services
Facility Health Information Management
Ancillary Departments
Administration
Nursing
Case Management/Quality
Service Centers
Finance
PURPOSE: To ensure that medical records for outpatient services and for inpatient services falling
within the Centers for Medicare and Medicaid Services (CMS) regulations for the Three Day
Window are processed and coded according to standards as outlined in this policy. Specific
guidelines on billing procedures are documented in the BILLING-Outpatient Services and Medicare
Three Day Window Policy, GOS.BILL.001.
POLICY: When Medicare claims are combined for billing purposes under CMS regulations for
Three Day Window, the outpatient medical records must not be combined with inpatient admission
medical records. Coded data will be combined for purposes of claim submission only.
For situations in which there is an immediate transfer from outpatient status to inpatient status with
no break in service, outpatient medical records must be combined with inpatient admission medical
records and the entire medical record must be coded as an inpatient admission.
PROCEDURE:
In addition to the steps listed in the BILLING-Outpatient Services and Medicare Three Day Window
Policy, GOS.BILL.001, the following must be performed to ensure that Medicare medical records are
processed in accordance with accepted standards:
1. If outpatient services are rendered and the patient is immediately transferred to inpatient status,
the registration personnel must use a single account number for use with the inpatient and
outpatient claim as this is considered to be one encounter.
a. The entire encounter, including any outpatient procedures, must be coded according to the
Coding Documentation for Inpatient Services Policy, HIM.COD.001.
b. The entire encounter must be abstracted under the single account number.
c. All documentation for the visit must be filed in one medical record admission.
d. Patient type should reflect inpatient status.
5/2004
DEPARTMENT: Health Information
Management Services
PAGE: 2 of 5
EFFECTIVE DATE: May 31, 2004
POLICY DESCRIPTION: Outpatient Services and
Medicare Three Day Window
REPLACES POLICY DATED: 4/3/98; 8/1/00;
6/1/02
REFERENCE NUMBER: HIM.GEN.001
e. Guidelines should be developed at the hospital to ensure consistency in determining which
single account number to use.
2. If outpatient services are rendered and the patient goes home, the registration personnel must use
one account number for the encounter.
a. This encounter must be coded according to the Coding Documentation for Outpatient
Services Policy, HIM.COD.002.
b. The encounter must be abstracted under the outpatient account number.
c. The outpatient record must be filed per the facility’s outpatient record filing policy and
procedure.
3. If a Part A acute Medicare inpatient admission occurs within three days of an outpatient service
provided at the same hospital, a new account number must be assigned for the inpatient
admission. (See the BILLING- Outpatient Services and Medicare Three Day Window Policy,
GOS.BILL.001.)
a. The outpatient encounter must be:
i. coded following the Coding Documentation for Outpatient Services Policy,
HIM.COD.002;
ii. abstracted under the outpatient account number; and
iii. filed per the facility’s outpatient record filing policy and procedure.
b. The inpatient admission must be:
i. coded following the Coding Documentation for Inpatient Services Policy, HIM.COD.001;
ii. abstracted under the inpatient account number; and
iii. filed per the facility’s inpatient record filing policy and procedure.
c. For billing purposes, Health Information Management (HIM) Department personnel must
review the inpatient and outpatient records in order to accomplish the following:
i. for any diagnostic outpatient service, provide Business Office, or Service Center staff
with the sequence of the combined outpatient and inpatient ICD-9-CM diagnosis and
procedure code(s) following the Coding Documentation for Inpatient Services Policy,
HIM.COD.001. Recalculate the DRG based on any coding changes and provide this
information to Business Office staff. See Attachment 1 for a list of revenue codes defined
as diagnostic; OR
ii. for non-diagnostic or therapeutic outpatient services, determine if the services are related.
If the services are not related, notify the Business Office or appropriate Service Center that
the claims should not be combined. Related services are defined as those in which there is
an exact match (for all digits) between the ICD-9-CM diagnosis code assigned for the
outpatient visit and principal ICD-9-CM diagnosis code assigned for the inpatient stay;
iii. for related non-diagnostic or therapeutic outpatient services, the claims must be combined.
5/2004
DEPARTMENT: Health Information
Management Services
PAGE: 3 of 5
EFFECTIVE DATE: May 31, 2004
POLICY DESCRIPTION: Outpatient Services and
Medicare Three Day Window
REPLACES POLICY DATED: 4/3/98; 8/1/00;
6/1/02
REFERENCE NUMBER: HIM.GEN.001
Related services are defined as those in which there is an exact match (for all digits)
between the ICD-9-CM diagnosis code assigned for the outpatient visit and principal
ICD-9-CM diagnosis code assigned for the inpatient stay; Sequence the diagnoses and any
procedure codes according to the Coding Documentation for Inpatient Services Policy,
HIM.COD.001; recalculate the DRG; and forward this information to Business Office or
Service Center staff for use in submitting the claim.
d. For accounts determined to meet the requirements for the Medicare three-day window,
Business Office or Service Center personnel must combine the inpatient and outpatient
charges for all related services and submit one claim for all related services as defined by
the BILLING-Outpatient Services and Medicare Three Day Window Policy, GOS.BILL.001.
4. If an inpatient admission subsequently occurs within three days of an outpatient service performed
in another hospital or entity that is wholly owned or operated by the admitting hospital, the
inpatient admission medical record is processed independently of the outpatient record from the
facility providing the outpatient services. (See the BILLING-Outpatient Services and Medicare
Three Day Window Policy, GOS.BILL.001.)
a. The inpatient admission must be:
i. coded at the admitting hospital following the Coding Documentation for Inpatient
Services Policy, HIM.COD.001;
ii. abstracted at the admitting hospital under the inpatient account number; and
iii. filed at the admitting hospital per the facility’s inpatient record filing policy and
procedure.
b. The outpatient encounter from the facility providing the outpatient services must be:
i. coded at the facility providing the outpatient service following the Coding Documentation
for Outpatient Services Policy, HIM.COD.002;
ii. abstracted at the facility providing the outpatient service; and
iii. filed at the facility providing the outpatient service.
c. HIM Department, Business Office, Service Center and/or Admitting/Registration personnel
from the admitting hospital must contact the HIM Department and Patient Accounts
Department personnel of the facility that provided the outpatient service in order to:
i. determine if claims must be combined; and
ii. compile charges and ICD-9-CM coded diagnoses and procedures for the outpatient
account meeting the criteria for the Three Day Window.
d. HIM Department personnel must combine the inpatient and outpatient codes according to the
Coding Documentation for Inpatient Services Policy, HIM.COD.001.
e. Business Office or Service Center personnel must combine charges for submission of the
inpatient claim.
5/2004
DEPARTMENT: Health Information
Management Services
PAGE: 4 of 5
EFFECTIVE DATE: May 31, 2004
POLICY DESCRIPTION: Outpatient Services and
Medicare Three Day Window
REPLACES POLICY DATED: 4/3/98; 8/1/00;
6/1/02
REFERENCE NUMBER: HIM.GEN.001
5. If an inpatient admission occurs within three days of an outpatient service performed in a
physician’s office that is wholly owned or operated by the admitting hospital (see the BILLINGOutpatient Services and Medicare Three Day Window Policy, GOS.BILL.001), the inpatient
admission medical record is processed independently of the physician office visit.
a. The inpatient admission must be:
i. coded at the admitting hospital following the Coding Documentation for Inpatient
Services Policy, HIM.COD.001;
ii. abstracted at the admitting hospital under the inpatient account number; and
iii. filed at the admitting hospital per the facility’s inpatient record filing policy and
procedure.
b. The outpatient encounter from the physician office providing the outpatient services must be
coded at the physician office providing the outpatient service following physician office
coding and documentation guidelines. HIM Department, Business Office and/or
Admitting/Registration personnel from the admitting hospital must contact physician office
personnel of the physician office that provided the outpatient service in order to:
i. determine if services must be combined on a single claim (technical component only); and
ii. compile charges and ICD-9-CM coded diagnoses and procedures for the services meeting
the criteria for the Three Day Window.
c. HIM Department personnel must combine the inpatient and outpatient codes according to the
Coding Documentation for Inpatient Services Policy, HIM.COD.001.
d. Business Office personnel must combine charges for submission of the inpatient claim that
meets Medicare Three Day Window criteria.
6. On a daily basis, the HIM Department personnel must discuss the “Three Day Window Report”
with Admitting/Registration and Business Office personnel to determine if any patients have
received outpatient services within the applicable “window.” Communication between HIM
Department, Admitting/Registration, and Business Office personnel must be established.
a. Admitting/Registration or Business Office personnel must communicate all occurrences of
outpatient services provided within the “window” of an inpatient admission that meet the
criteria as defined in the BILLING-Outpatient Services and Medicare Three Day Window
Policy, GOS.BILL.001.
b. HIM Department personnel must review all accounts in the Three Day Window in order to
provide the accurate sequencing of codes and DRG recalculation following the above
procedures.
7. Review of remittance advice rejections relation to this policy and the BILLING - Outpatient
Services and Medicare Three Day Window Policy, GOS.BILL.001 must be performed by the
HIM Department, Business Office or Service Center at least semi-annually (or more frequently as
5/2004
DEPARTMENT: Health Information
Management Services
PAGE: 5 of 5
EFFECTIVE DATE: May 31, 2004
POLICY DESCRIPTION: Outpatient Services and
Medicare Three Day Window
REPLACES POLICY DATED: 4/3/98; 8/1/00;
6/1/02
REFERENCE NUMBER: HIM.GEN.001
directed by company initiatives or facility leadership) and the results reported to the Facility
Monitoring Oversight Group. Reasons for rejection and resolution strategies must be documented
in accordance with the Coding Documentation for Inpatient Services Policy, HIM.COD.001.
8. The HIM Department, Admitting/Registration, and Business Office or Service Center must
develop a communication tool to ensure compliance with this Policy.
DEFINITIONS:
Window: Three (3) calendar days prior to an inpatient admission for acute care Prospective Payment
System (PPS) (DRG reimbursed) facilities/units and one day prior to an inpatient admission for
hospitals or units exempt from acute care PPS.
Diagnostic Services: An examination or procedure to which the patient is subjected, or which is
performed on materials derived from a hospital outpatient, to obtain information to aid in the
assessment of a medical condition or the identification of a disease. Among these examinations and
tests are diagnostic laboratory services such as hematology and chemistry, diagnostic X-rays, isotope
studies, EKGs, pulmonary function studies, thyroid function tests, psychosocial tests and other tests
given to determine the nature and severity of an ailment or injury. See GOS.BILL.001 for additional
information.
Non-Diagnostic Services: Services and supplies furnished as an integral, although incidental, part of
a physician's professional service in the course of diagnosis or treatment of an illness or injury.
Related Services: Services are related when there is an exact match (for all digits) between the ICD9-CM principal diagnosis code assigned for both the outpatient services and the inpatient stay.
REFERENCES:
Federal Register, February 11, 1998, Vol. 63, No. 28, pp.6864-6869
St. Anthony’s Medicare Billing Compliance Guide (pp 6-10 through 6-14) & (pp 8-75 through 8-79)*
American Hospital Association –Legal Update #6 and #7*
Coding Documentation for Inpatient Services Policy, HIM.COD.001
Coding Documentation for Outpatient Services Policy, HIM.COD.002
Outpatient Services and Medicare Three Day Window Policy, GOS.BILL.001
*Non-Authoritative Resources
5/2004
ATTACHMENT 1
Revenue and/or HCPCS Codes Meeting Criteria for Diagnostic Services
254 Drugs incident to other diagnostic services
255 Drugs incident to radiology
30X Laboratory
31X Laboratory pathological
32X Radiology diagnostic
341 Nuclear medicine, diagnostic
35X CT scan
40X Other imaging services
46X Pulmonary function
48X Cardiology with CPT codes (includes but are not limited to): 93015, 93307,
93308,
93320,
93501,
93503,
93505,
93510,
93526,
93541,
93542,
93543,
93544, 93545,
93561, or
93562
53X
Osteopathic services
61X
MRI
62X
Medical/surgical supplies, incident to radiology or other diagnostic services
73X
EKG/ECG
74X
EEG
92X
Other diagnostic services
Note: Any services, items and/or supplies that are integral to the performance of a diagnostic
procedure also need to be combined with the inpatient admission. For example, pharmacy items
and injections provided in conjunction with a diagnostic radiology procedure subject to the three
day window, must also be combined with the inpatient account.
Attachment to HIM.GEN.001