Friday, September 24, 2021

The Other Side of the 14 Day Rule: The 3 Day Rule (72 Hour, PreAdmission Rule)

There's a "14 Day Rule" that bundles genomic lab tests to inpatient stays for 14 days after discharge.  

Did you know there is also a "3 Day Window" Rule, that bundles lab tests to a DRG, for 3 days in advance of admission?


I wrote a blog explaining the 14 Day Rule for outpatient lab tests in 2015, which is still up - here.  The major update since then was a Fall 2017 rule, supposed to be effective January 2018, actually effective January 2020, that genomic tests should be billed by the lab that performed them for outpatient specifics in a 14 day window.  See CMS home page for 14 Day Rule here.

I'm gearing up to speak on a panel about the 14 Day Rule and lung cancer patients on October 14, 2021.  This is the Foundation for Lung Cancer, Go-2 Summit, CEnters of Excellence Summit.  Home page, agenda, and registration here.

14 Day Rule - Background

See 2015 blog for illustrations.  The starting point is that the date of service is the date of specimen collection (whether for hospital inpatient or hospital outpatient).  This remains the date of service UNLESS a test is ordered by the treating physician more than 14 days after discharge.   For an outpatient, the date of specimen collection and "date of discharge" are probably the same.   For an inpatient, the date of discharge might even be after the 14th day after the specimen collection.  

(For example, a patient is admitted for lung cancer surgery on July 1, has actual surgery on July 2, and is discharged on July 30.  The physician orders the genomic test on August 3.  The triggering date is a physician order 14 days after discharge (not 14 days after surgery), so the physician order must be August 14 or later to reassign the Date of Service, even though the surgery was July 2.)

New News: There's Also  3-Day, or 72-Hour Rule

Diagnostic test bundling also applies for 3 days PRIOR to a hospital admission.  I was aware of this but had never looked up the laws and regulations.   This "3-Day" or "72-hour" rule is complex in its own way.  The CMS term CMS to usually be, "3 Day Payment Window" which implicates this policy applied 3 days before a hospital admission and the start of a DRG payment.

(It's actually a "3 Day Non Payment Window"...)

72-hour bundling dates of pre-admission lab tests dates back decades, and was probably meant to cover routine pre-op tests (blood clotting, urinalysis, CBC).   The Claims Manual (link below) gives rules for claims processing era by era ("For Claims prior to January 1, 1990," we read.) 

But: The 3 Day Window was most recently adjusted by a 2010 law.  Not the ACA, but rather the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010,” Pub. L. 111-192.   This requires bundling of all diagnostic services provided 72 hours prior to admission, AND generally requires bundling of all non-diagnostic services EXCEPT IF the hospital can make an affirmative argument that the non-diagnostic services aren't related to the admission.   At the time, the rule was expected to save $4B over ten years (here).

However, this applies to the admitting hospital and any wholly-owned entity under it.  If I've read some explanatory articles correctly, if Entity A owns Hospital Y and MRI Center Z, then MRI's done at Center Z don't require bundling, because Z is not "wholly owned" by the admitting Hospital Y.   (That's my understanding from what I've read, but I'm not an attorney).

Rarely, 3-Day Window Could Make Genomic Tests Bundled?

One could imagine a setting where a hospital runs an on-site 300-gene tumor test on an outpatient July 1, and there'd admitted for a sudden worsening of their cancer on July 3, in which case the 72-hour rule might apply.   Interesting to know.   

Resources on the 3 Day Payment Window
  • The 2010 law is here, the bundling rule is at Section 102.  
  • The law is codified at SSA 1886(a)(4).  Here.
  • CMS isn't given much discretion, because the 72-hour pre-bundling is baked into the hospital payment statute.
  • Regulations are 42 CFR 412.2, here.
  • Manual instructions are at Inpatient Claims Manual, Ch 3, Section 40.3, here.
Further handy explanatory resources include:
  1. CMS FAQ on 72 Hour Rule here.
  2. CMS Home Page for 72 Hour Rule here.
  3. Original Implementing Memorandum here.
  4. Consulting firm Conduent discusses (Andrew Townsend) here.
  5. OIG report, 2020, claiming that CMS pays in appropriately for services that should be in the 72 hour bundle, here.