Certified Revenue Cycle Representative (CRCR) Practice Exam

If a Medicare patient is admitted on Friday, which services are included in the three-day DRG window rule?

1. Only diagnostic charges on Friday

2. All services since the previous Monday

3. Diagnostic and clinically-related non-diagnostic charges provided on the preceding Tuesday to Friday

4. Only services billed prior to admission

The correct answer is: Diagnostic and clinically-related non-diagnostic charges provided on the preceding Tuesday to Friday

The correct answer is that the three-day DRG window rule includes diagnostic and clinically-related non-diagnostic charges provided on the preceding Tuesday to Friday. This rule is significant in the context of Medicare reimbursement because it determines what services are bundled into the payment for the inpatient stay under the Diagnosis Related Group (DRG) system. When a patient is admitted to the hospital, Medicare looks at a specific timeframe before the admission—specifically, three days prior—in assessing what services are related to the inpatient admission. This is designed to ensure that any relevant diagnostic or medically necessary services are accounted for in the DRG payment. Services that are clinically related to the primary diagnosis during this three-day period are included in the DRG payment, making it critical for healthcare providers to understand which charges can be bundled. This directly helps in accurate billing and optimizes the reimbursement process for services rendered. In contrast, the other options do not capture the full scope of the rule. For example, stating that only diagnostic charges on Friday are included fails to recognize the broader timeframe of related services. Limiting the services to those since the previous Monday does not align with the specific three-day window leading up to the admission, and focusing only on services billed before admission disregards the importance