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Part of the Centers for Medicare & Medicaid Services’ (CMS) prospective payment system, the rule as originally issued requires hospitals to bundle any charges for outpatient diagnostic or other services related to a patient’s admission that are provided during the three-day period preceding admission under the inpatient claim.However, the definition of other services remained an ongoing point of contention, leading to a 2011 CMS clarification on how the rule should be applied to certain outpatient services.Specifically, the agency defined other services to include any outpatient service that is clinically associated with the reason for admission.Further, any outpatient nondiagnostic services provided within the three-day time frame would be considered admission related unless the hospital verifies they are clinically distinct and unrelated.(a) No prescription for a controlled substance listed in Schedule III or IV shall be filled or refilled more than six months after the date on which such prescription was issued.No prescription for a controlled substance listed in Schedule III or IV authorized to be refilled may be refilled more than five times.(b) Each refilling of a prescription shall be entered on the back of the prescription or on another appropriate document or electronic prescription record.If entered on another document, such as a medication record, or electronic prescription record, the document or record must be uniformly maintained and readily retrievable. (4) The initials of the dispensing pharmacist for each refill.
Miller, CPA, CAPPM, manager of Hayflich & Steinberg CPAs, PLLC and president of the National CPA Health Care Advisors Association.
(e) The prescribing practitioner may authorize additional refills of Schedule III or IV controlled substances on the original prescription through an oral refill authorization transmitted to the pharmacist provided the following conditions are met: (1) The total quantity authorized, including the amount of the original prescription, does not exceed five refills nor extend beyond six months from the date of issue of the original prescription.
(2) The pharmacist obtaining the oral authorization records on the reverse of the original paper prescription or annotates the electronic prescription record with the date, quantity of refill, number of additional refills authorized, and initials the paper prescription or annotates the electronic prescription record showing who received the authorization from the prescribing practitioner who issued the original prescription.
Many hospital coding and billing departments continue to struggle with the nearly 20-year-old definition of “other services” as related to Medicare’s so-called 72-hour rule—more accurately defined as the three-day payment window.
The resulting misapplication forces many facilities to leave reimbursement dollars on the table rather than risk demands for repayment and potential financial penalties.