Billing During an Inpatient Stay (the 48-Hour Rule)

What You Need to Know

Because hospitals receive a global payment for all items delivered during an inpatient stay, Medicare presumes that any prosthesis or brace dispensed while the recipient is still a hospital patient is included in that payment. The 48-Hour Rule is a limited exception to that presumption. A supplier can only bill Medicare Part B for a prosthesis or brace delivered to patients before their discharge if all 9 of the following criteria are satisfied:

1. The item is medically necessary for use in the patient's home;
2. The prescription has an initial date of need that pre-dates the patient’s discharge;
3. You deliver the item to the patient in the facility only for fitting or training;
4. You deliver the item to the patient in the facility 48 hours or less from their discharge;
5. You ensure that the patient takes the item home or you deliver it to their home on the discharge date;
6. You are not trying to save the hospital the cost of paying for something already included in its global fee;
7. You don’t claim payment for the item for any day before discharge;
8. You don’t bill patients for delivery costs if you deliver to their home on the discharge date; and
9. The patient is discharged to their home - not to another inpatient facility or SNF.

 -If you cannot satisfy all 9 requirements, you must bill the hospital directly for the item you've provided the patient.

What This Means for You

The starting point for 48-Hour Rule compliance is to remember that it is a limited exception to a general rule stating that items dispensed to an inpatient are part of the global payment made to the hospital. When the 48-Hour Rule doesn't apply, you must bill the hospital directly for the item delivered to the inpatient prior to discharge. 

If Medicare determines that you are charging Part B for items that should've been part of the Part A global payment, you can expose your business to charges that it is engaging in a kickback scheme with the hospital by removing a cost it should have borne from its balance sheet. Ongoing noncompliance with the 48-Hour Rule could lead investigators to infer that your intent was to secure ongoing referrals from the hospital by relieving it of a charge it should have been paying.

Where the 48-Hour Rule does legitimately apply, your records should clearly state that the prosthesis or brace was provided to the patient in the hospital purely for fitting or training purposes - not for use in the hospital pre-discharge. Document in detail the specific fitting you performed or training you provided.

Finally, before billing Medicare Part B, you should always confirm the patient's discharge date. If unanticipated delays push the patient's discharge beyond the 48-hour window, you cannot defend billing Medicare Part B by stating you had a good-faith belief that you had satisfied the 48-hour requirement.

The specific language of the 48-Hour Rule can be found in the Medicare Claims Processing Manual, Chapter 20, Sections 110.3 - 110.3.3.