MACs creating additional obstacles
In addition to the complicated nature of separating out the individual claims, providers may have received inaccurate information from their Medicare Administrative Contractor (MAC). During the CMS Hospital Open Door Forum in January, a caller explained that a contractor advised that if services are clinically related that they must be combined on the inpatient claim regardless of whether the diagnoses match, which simply isn't true.
"Providers read the information and try to apply it correctly, but are then told by the MAC that they are wrong and that they must be grouped together," says Hoy. "The rule states that there has to be an exact match of the diagnosis code on the inpatient and outpatient claims and CMS confirmed that on the recent Open Door Forums."
Despite all the perplexity of the three-day payment rule window, there are a number of options for providers to avoid problems.
If a provider is receiving inaccurate information from a contractor, he or she can work with the Regional Office to get the contractor to apply the rule correctly to the claims. If the problem is an internal one, read the rule carefully in the Medicare Claims Processing Manual and make sure that the practice's policies are in compliance with the rule and that even though the practice may think it is being conservative by lumping everything into the inpatient claim, it's not how CMS looks at it, according to Hoy.