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MIR-2006-8A, August 2006
DRG Window Edits
The Centers for Medicare & Medicaid Services (CMS) issued CR4089 in which the Common Working File (CWF) system changes were implemented April 3, 2006. CMS instructed CWF to make additional changes that were not included in the CR for edits C7109, C7112, C7113, C7114, C7115, C7119, C7120, C7121, and C7122.
This article was originally published in Medicare News Update 2002-11, November 2002. The charts below have been updated with these changes. |
It has come to the attention of Empire Medicare Services that some providers are still confused regarding the regulations for the Diagnosis Related Group (DRG) window.
Diagnostic services (including clinical diagnostic laboratory services) provided to a beneficiary by the admitting hospital during the three days prior to the date of admission are deemed to be inpatient services, and reimbursement is included in the inpatient payment unless the beneficiary does not have Medicare Part A coverage.
Section 110 of Public Law 103-443, reduces the pre-admission payment window for diagnostic services from three days to one day for hospitals and units excluded from PPS.
Other Pre-Admission Services
Nondiagnostic outpatient services provided by the admitting hospital within three days of a hospital admission that are related to the hospital admission are deemed to be inpatient services. The reimbursement for the services is included in the inpatient hospital payment. This only applies when the patient has Medicare Part A coverage. Pre-admission services are related to the admission if they are furnished in connection with the principal diagnosis that necessitated the inpatient admission to the hospital.
NOTE: The term “admitting hospital” includes any entity wholly owned or operated by the hospital or by another entity under arrangement with the hospital. This includes hospital outpatient services rendered to a patient who is admitted to a PPS-excluded unit.
DRG Window Editing
Crossover edits identify claims where inpatient and outpatient service dates overlap, or services are billed as outpatient, which should be included in the charges for an inpatient stay.
- Reason Codes C7119 (outpatient) and C7120 (inpatient) edit for diagnostic services provided one day prior to or equal to the day of admission to a non-PPS facility.
- Reason Codes C7121 (outpatient) and C7122 (inpatient) edit for therapeutic services one day prior to or equal to the day of admission to a non-PPS facility.
- Reason Codes C7109 (outpatient) and C7113 (inpatient) edit for diagnostic services related to the admission within three days of the admission.
- Reason Codes C7114 (outpatient) and C7115 (inpatient) edit for therapeutic services related to admission within three days of the admission.
Revenue Codes Related to Diagnostic Services
If a revenue code from this list is present on the outpatient claim, the claim will be rejected regardless of the diagnosis code on the inpatient claim.
254 Drugs incident to other diagnostic services
255 Drugs incident to radiology
30X Laboratory
31X Laboratory - Pathology
32X Radiology - Diagnostic
341 Nuclear Medicine, Diagnostic
343 Diagnostic Radiopharmaceuticals
35X CT Scan
371 Anesthesia Incident to Radiology
372 Anesthesia Incident to Other Diagnostic Services
40X Other Imaging Services (excluding Revenue code 0403)
46X Pulmonary Function
471 Audiology - Diagnostic
48X Cardiology - is present with one of the following HCPCS: 93015, 93307, 93308, 93320, 93501, 93503, 93505, 93510, 93526, 93541, 93542, 93543, 93544-93552, 93561, or 93562
53X Osteopathic Services
61X Magnetic Resonance Imaging
62X Medical/Surgical Supplies
73X EKG/ECG
74X EEG
75X Gastrointestinal Services
918 Behavior Health Treatment Services/Testing
92X Other Diagnostic Services
Revenue Codes Related to Therapeutic Services
If the principle diagnosis codes on the inpatient and outpatient claims are the same and the outpatient claim contains one of the following revenue codes, the claim will be rejected.
250 Pharmacy - General Classification
251 Pharmacy - Generic Drugs
252 Pharmacy - Non Generic Drugs
256 Pharmacy - Experimental Drugs
257 Pharmacy - Nonprescription Drugs
258 Pharmacy - IV Solutions
259 Other Pharmacy
27X Medical/Surgical Supplies and Devices
28X Oncology
33X Radiology -Therapeutic
340 Nuclear Medicine - General Classification
341 Nuclear Medicine - Therapeutic
349 Other Nuclear Medicine
36X Operating Room Services
370 Anesthesia - General Classification
373 Anesthesia - Acupuncture
379 Other Anesthesia
41X Respiratory Services
42X Physical Therapy
43X Occupational Therapy
44X Speech Therapy
45X Emergency Room
472 Audiology - Treatment
49X Ambulatory Surgical Care
51X Clinic
52X Freestanding Clinic
56X Medical Social Services
622 Surgical Dressings
63X Drugs Requiring Specific Identification
70X Cast Room
71X Recovery Room
72X Labor/Delivery Room
76X Treatment or Observation Room
79X Lithotripsy
90X Psychiatric/Psychological Treatment
91X Psychiatric/Psychological Services – (excluding revenue code 0918)
94X Other Therapeutic Services
Outpatient within Inpatient/SNF (C7050 and C7080)
Outpatient claims which overlap processed inpatient claims that do not reject as duplicates in the Fiscal Intermediary Shared System (FISS) will be rejected from the Common Working File (CWF) with one of the following reason codes.
C7050 This outpatient claim date of service overlaps an inpatient or SNF claim for the same provider.
C7080 This outpatient claim date of service overlaps an inpatient or SNF claim for a different provider.
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