CurrentPriority HealthPolicy BILLING POLICY No. 034

Three-Day Window

Governs bundling and reimbursement of outpatient diagnostic and related non-diagnostic services occurring within three days (or one day for certain facilities) of an inpatient admission for all Priority Health products and providers.

Policy Summary

PayerPriority Health

PolicyThree-Day Window

Policy CodePolicy BILLING POLICY No. 034

Change TypeNo material changes (reviews only)

Effective DateJuly 2024

Next Review Date2027-02

Key ActionUse Condition Code 51 to attest outpatient facility services unrelated to the admission and include supporting documentation to avoid denial or recoupment.

SourceLink

POLICY UPDATE CHANGES

Added 'Disclaimer' section.

Feb. 2026 review completed with no changes.

3-day / 1-daybundling window

All productsproducts

0254, 0255, 0341, …sample revenue codes

Condition Code 51attestation mechanism

Coverage and Bundling Rules

Policy Summary

PayerPriority Health

PolicyThree-Day Window

Policy CodePolicy BILLING POLICY No. 034

Change TypeNo material changes (reviews only)

Effective DateJuly 2024

Next Review Date2027-02

Key ActionUse Condition Code 51 to attest outpatient facility services unrelated to the admission and include supporting documentation to avoid denial or recoupment.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Bundling Criteria

Services performed within the specified pre-admission windows are generally included in DRG payment and are not separately reimbursed unless specific exclusions, attestation, or proper modifiers are applied.

Outpatient diagnostic and related non-diagnostic services provided within 3 days of an inpatient admission (or within 1 day for specified facility types) are considered part of the DRG and not reimbursed separately.

Exceptions (ONE of)

Ambulance services may be excluded from bundling.
Outpatient maintenance renal dialysis services may be excluded from bundling.
Services furnished by skilled nursing facilities, home health agencies, and hospices may be excluded from bundling.
Diagnostic services rendered during ER visits 48 to 72 hours prior to admission are considered part of the ER visit and excluded from DRG payment only within a Critical Access Hospital (CAH).

Documentation and Attestation

Condition Code 51 may be used on outpatient facility claims to attest that a preadmission non-diagnostic service is unrelated to the inpatient admission; the service must be clinically distinct from the reason for admission and supported in the medical record.
Priority Health may request supporting documentation and perform pre- or post-claim reviews; failure to document services as unrelated may result in claim denials or recoupment.

Modifier and Professional Component Rules

Related-entity professional services for preadmission diagnostic or non-diagnostic services must report the appropriate CPT/HCPCS code with the PD modifier when the patient is admitted within three days; claims accurately reported with PD will be reimbursed for the professional component when applicable.
Technical components of non-diagnostic services furnished by a related entity that is a physician practice/office on the date of admission are always deemed related to the admission and included in DRG payment.

Outpatient services followed by admission before midnight of the following day are treated as inpatient services and included in the DRG.

Affected Codes and Time Window

Revenue codes for technical component servicesmixedCovered

0254	Drugs incident to other diagnostic services (revenue code)
0255	Drugs incident to radiology (revenue code)
0341	Nuclear medicine, diagnostic (revenue code)
0343	Nuclear medicine, diagnostic radiopharmaceuticals (revenue code)
0371	Anesthesia incident to Radiology (revenue code)
0372	Anesthesia incident to other diagnostic services (revenue code)
0471	Audiology diagnostic (revenue code)
0481-0489	Cardiology, Cardiac Catheter Lab/Other Cardiology (revenue codes)
0482	Cardiology, Stress Test (revenue code)
0483	Cardiology, Echocardiology (revenue code)

1–10 of 11

1/2

Time window (inv-03)

Bundling periodServices occurring within three days of an inpatient hospital admission are considered part of the DRG and not separately reimbursed (one-day window applies for specified non‑IPPS facilities)

Included service typesDiagnostic services (including clinical laboratory) and related non‑diagnostic services provided by the admitting hospital or hospital‑owned entity prior to admission are deemed inpatient and included in the DRG

Admissions before midnightOutpatient services followed by admission before midnight of the following day are treated as inpatient services and part of the DRG

Technical component ruleTechnical components of non‑diagnostic services furnished by a related physician practice/office on the date of admission are always deemed related to the admission

Documentation, Modifiers, and Attestation Requirements

Documentation Required

Documentation and Authorization — Priority Health may request supporting documentation

Priority Health may request supporting documentation and perform pre- or post-claim reviews to validate services billed and ensure accurate claim processing and reimbursement. Authorization and medical necessity requirements appropriate to the procedure, diagnosis and frequency remain required; an authorization is not a guarantee of payment.

Failure to document services rendered or items supplied will result in a denial.
Payment integrity reviews may be performed to prevent fraud, waste and abuse; noncompliance can lead to claim denial, rejection, or recovery/recoupment.

Billing Rule

Condition Code 51 Attestation required for unrelated outpatient non-diagnostic services

Use Condition Code 51 on outpatient facility claims to attest that non-diagnostic preadmission services are unrelated to the inpatient admission; the service must be clinically distinct from the reason for admission and supported in the medical record. Omission or incorrect reporting may result in denials or recoupment.

Condition Code 51 is for outpatient facility claims to exclude unrelated non-diagnostic services from bundling.
To be considered 'unrelated,' the service must be clinically distinct and documented in the medical record; unsupported attestations may be denied or recouped.

Billing Rule

PD Modifier Requirement for related-entity professional services

Related-entity professional services must report the appropriate CPT/HCPCS code with the PD modifier when the patient is admitted within three days; omission of the PD modifier may lead to denial or recoupment. Facilities are responsible for notifying related entities of admissions occurring within the three-day/one-day period.

Claims reported with the PD modifier will be reimbursed for the professional component when applicable; services without a technical/professional split will be reimbursed at the facility rate.
Omission of the PD modifier is treated as an attestation that services were unrelated and must be supported by documentation; failure to accurately code may result in post-payment recovery.

Key Definitions

Three‑day/One‑day window (inv-07)

DefinitionThree‑day window: Services occurring within three days of an inpatient admission are generally bundled into the DRG; one‑day window applies for specified non‑IPPS facilities

Excluded servicesAmbulance, outpatient maintenance renal dialysis, services by SNFs, home health agencies, and hospices may be excluded from bundling

ER timing exceptionDiagnostic services during ER visits 48–72 hours prior to admission are excluded from DRG payment within Critical Access Hospitals (CAH) only

Unrelated non‑diagnostic servicesUnrelated non‑diagnostic preadmission services may be excluded when accurately reported and supported in the medical record (see Condition Code 51)

PD modifier (inv-08)

PD modifier definitionPD modifier: Diagnostic or related non‑diagnostic item or service provided in a wholly owned or operated related entity to a patient who is admitted as an inpatient within three days

Reporting requirementRelated entities providing professional services must report the appropriate CPT/HCPCS code along with the PD modifier for preadmission services when the patient is admitted within three days

Reimbursement effectClaims accurately reported with the PD modifier will be reimbursed for the professional component when applicable; services without a technical/professional split will be reimbursed at the facility rate

ResponsibilityRelated entities are responsible for accurate claim submission; facilities must notify related entities of admissions for services provided within the three‑day/one‑day period

Condition Code 51 (inv-09)

Condition Code 51 purposeAttestation that outpatient non‑diagnostic services are unrelated to the inpatient admission; used on outpatient facility claims to exclude services from bundling

Clinical support requirementTo be considered unrelated, the preadmission non‑diagnostic service must be clinically distinct from the reason for admission and supported in the medical record

Reporting consequenceOmission or incorrect reporting of Condition Code 51 may result in claim denials or recoupment through post‑payment audit