Experiencing Revenue Loss? Reimbursed Your Claims Under the 72 Hour Rule in Medical Billing

72 hour rule is another measure from CMS that is necessary for a smooth medical billing workflow. CMS promotes payment submission within a time frame, which is why implementing the 72-hour inpatient rule is necessary for providers to avoid complex billing issues. 

72 hour rule essentially requires collective billing for outpatient services that are combined with inpatient facilities rather than submitted separately. The rendered service claims should be proposed within a 72 hour rule in medical billing (three calendar days) before an inpatient admission. 

This approach promotes billing accuracy, compliance, and proper reimbursement while minimizing the risk of fraudulent claims. The article will guide what the 72 hour rule is for hospitals, where it applies and what its inclusions and exclusions are so the provider gets maximum revenue benefits.

What is 72 hours rule in medical billing

“The Medicare 72-hour rule explains the outpatient diagnostic services that must be bundled with inpatient claims under 3 days, which is set by the Centres for Medicare and Medicaid Services.”

The USA medical billing follows the 72 hour rule. Outpatient services combine for billing with hospital services and facilities within 3 calendar days. These critical claims are bundled together, not submitted separately, to reimburse payments in a timely manner.

Importance of 72 Hour Rule in Revenue Cycle Management

Following the 72-hour rule in medical billing helps avoid overpayments and underpayments. All outpatient services related to patient admission for in-house treatment are billed on a single claim rather than as separate claims. Such negligence in claim submission can lead to claim denial, which extends the reimbursement process. To deal with it, consulting denial management services make billing efficient and reimbursement easy for providers and payers by adhering to the 72-hour rule.

Services Included and Excluded in 72 Hour Medicare Rule

Some factors can complicate the CMS 72 hour rule, like different diagnoses that make the claim to be included or excluded from Medicare 72 hour rule emergency room. Patients visit healthcare clinics and hospitals for emergency treatments. This is why providers wait for the diagnostic result before taking the next step. Outpatient diagnostic services can only be attached to an inpatient claim when the patient is admitted for treatment.

A medical billing specialist from an outsourcing company is a step toward making the billing system smoother and more efficient and ensuring financial stability.

If the patient gets outpatient services from another clinic and is admitted to another for treatment, then the rule will not be applicable. Otherwise, getting services for inpatient and outpatient from the same organization can follow the 72-hour rule.

Exception of 72-Hour Rule to Medicaid Services

Medicaid is a joint healthcare program run by both the federal and private sectors. Applying 72 hour rule to Medicaid is positive, but states are more likely to operate their own policies or to modify the 72-hour rule. So providers follow different payment windows or may have no bundling rule. So, there are 3 exceptions to the CMS 72 hour rule. 

1- Medicaid services are excluded.

2- Different health facilities render services.

3- Non-diagnosis services.

7 Benefits of Applying the CMS 72 Hour Rule Claim Submissions

The 72-hour rule prevents issues such as unbundling and claim rejections from arising. Among its benefits, compliance with medical billing is considered one of the most significant advantages. Furthermore,

• It prevents claims from rejection.
• Streamline billing and reduce complex billing.
• Reduced administrative burden.
• Reduce audit risks.
• Reduce costly medical billing work cycle.
• Create timeline compression to speed up the workflow.

3 Common Challenges Providers Face in the 72 Hour Rule 

Implementing the Medicare 72 hour rule can be difficult for healthcare clinics to follow. Mostly, there are many claims in line for submission. This requires efficient, attentive staff who are trained on an updated system. Here are 3 common challenges providers face with the 72-hour rule.

• The likelihood of documentation errors increases.
• Ignoring code placement with different modifiers in medical billing for operational facilities.
• Falling into bundled diagnoses that make the claim complex.

Best Practices that Enhance 72 Hour Rule Implementation

The 72-hour rule in medical billing improves the billing workflow. But turning to electronic-driven solutions can enhance the 72 hour rule in medical coding. Here are some best practices for the billing process that boost revenue and reduce billing burdens.

• Staff training and education on the updated system increase work quality and efficiency.
• Implement an electronic health record system for tracking patients’ records to check the 72 hour rule claim eligibility.
• Use updated billing software that handles claims that are billed with inpatient claims.
• Establish a documented policy for staff and payers so they can review it once before taking further steps for claims.

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Consulting Outsourcing for Speeding Up the Reimbursement

The outsourcing setup offers different structures for their partners with customized solutions. Star Billing Solutions avoids cost challenges for medical billing claim submission. Their integration with electronic system compliance with the 72-hour rule in medical billing fastens the reimbursement rate and increases profits through reliable resources.