Examples of 3-Day Payment Window UNbundling

Examples of services that can/should be unbundled from the IP stay include:

All revenue code 450
Revenue code 250, 270
PT, OT, ST, RT
Example 1 - A patient has OP surgery via a colonoscopy. Benign Polyp(s) were removed and patient is sent home following the OP surgery (ICD-9-CM code 211.3). Within 24 hours, the patient has acute abdominal pain and rectal bleeding, is admitted to hospital, found to have a small perforation on the large intestine and is taken to surgery for treatment. The principal diagnosis for the IP stay is “complication post colonoscopy with perforation” (ICD-9-CM code 998.2 ). Are the two services related? No. Although a clinical match, the principle diagnosis codes are not a match, so the claims should not be combined.
Example 2 - Patient presents to the ER with acute bronchitis (ICD-9-CM code 466.0), goes home and returns two days later with pneumonia (ICD-9-CM code 486). Are the two services related? No. The hospital should bill the non-diagnostic services separately with the ER visit as an OP claim. The diagnostic services should be combined on the IP bill.
Example 3 - Patient has an outpatient PTCA for CAD, coded 414.01, and is admitted as an inpatient for cardiac arrest due to the procedure, coded 997.1 and 427.5. The diagnosis codes do not match, therefore, the inpatient billing should not include the procedure. The procedure (PTCA) should be billed to Part B. (Reference: CMS Transmittal A-03-013, Change Request 2573, 14 February 2003).

Additional Reference:

Medicare Claims Processing Manual 100-04, Section 40.3, 21 October 2005 - http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf

Additional Information