CMS 72 hour rule
The CMS 72 hour rule is one of the many laws in place to help make the Medicare program run smoothly. The Centers for Medicare & Medicaid Services (CMS) sometimes refers to their three-day rule as the 72‐hour rule.
This rule states that outpatient diagnostic or other services preformed within 72 hours before a hospital stay must be billed as part of the hospital stay. The hospital cannot bill these diagnostic tests as separate procedures.
Click here to view the CMS 72-rule information
When a beneficiary undergoes diagnostic services within 3 days before a hospital stay, the services are considered inpatient and are included with the bill for the hospital stay. This is true for any diagnostic test or service provided in the hospital facility within a 3-day period before a patient’s admission.
A few examples of outpatient diagnostic services that the rule applies to include:
- Lab tests
- Radiology
- CT Scans
- Cardiology
- EKG
- EEG
- Nuclear Medicine
- Osteopathic test
Other times hospitals may add in-patient services together
In some instances, under the 72-hour rule, hospitals may bundle unrelated outpatient services with an inpatient surgery. Although, if the outpatient service is not diagnostic, the hospital can bill it as a separate charge.
Medicare agents, watch a quick YouTube video on the CMS final rule 2024 for agent compensation
To better understand; please take a look at the example below.
If a beneficiary has an in-patient surgery scheduled in the next 3 days, but she trips and falls and goes to the hospital for an x-ray, the hospital can include the bill for her x-ray with her in-patient surgery bill. This is true even if it is un-related. In most cases, the patient receives a separate bill for the individual service. If this patient has in-patient surgery within 3 days of the diagnostic test (x-ray), the hospital adds the cost of the x-ray with the surgery charges. The surgery can be completely unrelated to the area she had an x-ray of.
It is important to note, that because the nature of the service provided was diagnostic, it can be included in the in-patient charges. Although, if the service a patient receives is not diagnostic but a service such as physical therapy, the provider bills this service separately and cannot include it in the in-patient bill.
How does the 72 hour rule help
CMS has this rule in place to stop providers from double-billing Medicare. Both CMS and the OIG (Office of Inspector General) actively enforce the rule. This helps prevent fraud and over payment for medical services. If a provider is caught not complying with this rule, they face thorough investigations as well as the responsibility of paying for the recovery of overpayments they received. Providers may also lose out on payments for services they provided.
The 72-hour rule helps limit both overpayments and underpayments. It is important that hospitals ensure their billing and coding representatives understand the rule and how to apply it.