Medicare has a new modifier for hospital-run urgent
cares.
The new HCPCS Level II modifier PD is
defined as “diagnostic or related
non-diagnostic item or service provided in a wholly owned or wholly operated
entity to a patient who is admitted as an inpatient within 3 days, or 1 day.”
This new modifier is being applied as a part of
CMS’ expansion of the “three-day payment window” for outpatient services
provided within 72 hours of an inpatient admission.
What this means is that Medicare pays a reduced
fee for services that are:
1) Clinically-related to an inpatient admission
2) Occur within 72 hours of the admission
3) Are provided by a facility owned or operated by
a hospital
The rule applies regardless of whether the
diagnoses codes are the same or different.
Although compliance with the Federal Rule is
delayed until July 1, 2012, hospital-run urgent cares should begin using
modifier PD on applicable claims now. CMS recommends that practices hold claims
for at least three days prior to submission just in case the patient is
admitted 72 hours later, which would necessitate the addition of modifier PD to
the claim.
Hospital-run urgent care centers will be
reimbursed the full amount for services that are “unrelated” to the hospital
admission, but CMS has not provided a definition for non-diagnostic services
that are considered “clinically related,” claiming that they prefer to make
that determination on a case-by-case basis. For this reason, many urgent care
consultants are recommending that clinics document the reasons why those
particular clinic visits are “not clinically related” to the patient’s hospital
admission to ensure they receive full payment.
For more information, see the November, 28, 2011 Federal
Register.
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