# BCBS 72 hour rule for inpatient billing



## gaoliver1987@gmail.com (Apr 13, 2016)

Hi everyone,

My current organization is having a billing issue that has a few teams in a communication dispute about whether we are billing these claims correctly. 

https://www.floridablue.com/sites/f...ocs/Billing Guidelines Section 4_1_2016_0.pdf

So that link can take you to the Florida Blue billing guidelines. On page 91 of the guidelines it speaks of inpatient billing guidelines and gives some insight as to how to bill a claim when a patient comes into the hospital and has services performed prior to being admitted to the hospital for an inpatient service. 

So one thing is definitely established. If the patient has a service longer than 72 hours prior to an inpatient stay, it does NOT go on the same claim as the inpatient stay. It is also well established that pre-operative testing related to the inpatient stay performed on the day prior to an inpatient stay goes on the same claim. such as a patient having a CT scan on day 1, gets a diagnosis, and then is admitted to inpatient status on day 2 for that related diagnosis. 

Where we are facing a LOT of denials is in relation to a situation where the patient comes into the ER, lets say 72 or 48 hours prior to the inpatient stay, then goes home for a day, and then comes back the next day to the hospital and is admitted to inpatient status. 

Most of these denials are not related to pre-operative testing. For instance, a common scenario is that the patient comes into the ER for pain related to the same diagnosis that has them scheduled for an inpatient stay. I will make up a scenario below.

Patient has Appendicitis and is scheduled to have their appendix removed on 04/03/2016. Patient's appendix hurts on 04/01/2016 so comes into the ER then leaves the ER with a prescription for pain killers and is told to come back in 2 days when their surgery is scheduled to have it removed. Patient comes back on 04/03/2016 for their surgery and complications result in the patient needing to be admitted to inpatient status for a day. Patient is then discharged on 04/04/2016. We do not bill room and board charges for date of discharge, so for this scenario we would bill one room and board charge. 

So our claim would have a from date of 04/01/2016 - 04/04/2016, with the ER visit on 04/01, no charges and 04/02 and then the inpatient procedure on 04/03. BCBS then routinely denies this claim for incorrect room and board charges, stating that we billed for the wrong # of room and board (we would bill for 1 in this case). Provider help lines are then very confused about the situation and when we explain the ER visit was related to the inpatient stay they don't know why the claim is bombing out in their system. Sometimes the rep will send the claim back to reprocess with a note attached (and it still doesn't pay), and sometimes they will adamantly state that we billed the claim wrong and need to correct it, without stating specifically what we did wrong relating to their billing guidelines. 

Can any of you offer guidance on this issue? I read the billing guidelines and feel like the 72 hour rule only applies to diagnostic procedures that result in an inpatient stay. Such as, patient comes into ER late on 04/01, gets a CT scan, receives a diagnosis of appendicitis, and then is admitted to inpatient status on 04/02 to have surgery to remove the appendix and is discharged on 04/03. Or a situation where the patient comes into the ER, gets diagnosed with "something", gets placed in observation for 24 hours, then gets admitted to inpatient status.  

Our billers on the other hand insist that if the patient comes into the ER, gets discharged, and then comes back 48 hours later for surgery all needs to be on the same claim, even if the ER visit did not result in a diagnosis or pertain to pre-operative testing. PLEASE PLEASE PLEASE someone offer help on this because BCBS and their guidelines aren't helpful at all. Thank you for any you can give.


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