Practice Management Alert

Question: I bill for a multi-specialty group that also has an urgent care facility. Our patients often go either from a visit with one of the specialists or from the urgent care facility to the hospital. I-ve heard that I need to be concerned with the 72/24 rule but I don't know what it is or how it applies. Can you please explain?

California Subscriber

Answer: If the hospital you admit the patients to does not own the urgent care facility, you should not have to worry about the 72/24-hour rule.

The so-called 72/24-hour rule states that you must consider all diagnostic and related non-diagnostic services a patient undergoes in the hospital as an outpatient within 72 hours prior to the date he is admitted to the hospital as an inpatient service. And as such, those services are included in the inpatient payment as long as the patient has Part A coverage.

Acute care hospitals, which are paid under the inpatient prospective payment system, follow the 72-hour rule and long-term care hospitals, inpatient rehabilitation hospitals and psychiatric hospitals follow the 24-hour rule. Critical access hospitals, however, are exempt from the 72/24 rule.

What it means for you: When your physician orders diagnostic services such as laboratory tests or x-rays at the hospital or a hospital-owned entity within 72 hours of the patient's admission to the hospital, the hospital cannot bill for those services as outpatient services, and if they bill, the payer will not pay. They will instead be part of the inpatient DRG. But you can bill for diagnostics your physician performs in your office or in a non-hospital owned facility.

Read on: For more information on this rule, you can refer to the CMS Internet Only Manual (IOM); Publication 100-4; Chapter 3; Section 40.3 at www.cms.hhs.gov/manuals/downloads/clm104c03.pdf.