Three Day Payment Window

Note: For hospitals and units excluded from IPPS, this provision applies only to services furnished within one day prior to and including the date of the beneficiary’s admission. Critical Access Hospitals (CAHs) are not subject to the 3-day (nor 1-day) DRG payment window.

Diagnostic services (including clinical diagnostic laboratory tests) provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), within 3 days prior to and including the date of the benefi ciary’s admission are deemed to be inpatient services and included in the inpatient payment, unless there is no Part A coverage.

The following revenue codes and/or HCPCS codes are defined as diagnostic services:  

Revenue Codes	Description
254	Drugs incident to other diagnostic services
255	Drugs incident to radiology
	Laboratory
30X	Laboratory pathological
31X	Radiology diagnostic
32X	Nuclear medicine, diagnostic/Diagnostic Radiopharmaceuticals
341,   343	CT scan
35X	Anesthesia incident to radiology
371	Anesthesia incident to other diagnostic services
40X	Other imaging services
46X	Pulmonary function
471	Audiology diagnostic
0481,0489	Cardiology, Cardiac Catheter Lab/Other Cardiology with CPT codes 93501, 93503, 93505, 93508, 93510, 93526, 93541, 93542, 93543, 93544, 93556, 93561, or 93562 diagnostic
482	Cardiology, Stress Test
483	Cardiology, Echocardiology
53X	Osteopathic services
61X	MRT
62X	Medical/surgical supplies, incident to radiology or other diagnostic services
73X	EKG/ECG
74X	EEG
918	Testing- Behavioral Health
92X	Other diagnostic services

Non-diagnostic outpatient services that are related to a patient’s hospital admission and that are provided by the hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), to the patient during the 3 days immediately preceding and including the date of the patient’s admission are deemed to be inpatient services and are included in the inpatient payment.

Note: CMS defines all non-diagnostic services except ambulance and maintenance renal dialysis services as related to the inpatient admission unless the hospital attests to specific non-diagnostic services as being unrelated to the inpatient hospital claim (that is, the preadmission non-diagnostic services are clinically distinct or independent from the reason for the beneficiary’s admission) by adding a condition code 51 to the separately billed outpatient non-diagnostic services claim.