Outpatient services included in reimbursement for inpatient services

Outpatient services rendered during an inpatient admission. 

IBC’s hospital inpatient reimbursement includes payment for all services provided (1) during the inpatient stay, (2) on the day of the admission, and (3) on the day of discharge. There is no additional payment for services billed on an outpatient basis. Charges for outpatient services rendered to the Member during the inpatient stay, on the day of the admission, and on the day of the discharge must be reported on the inpatient claim. If a hospital submits a separate claim for outpatient services that were, or should have been, reported on the Member’s inpatient claim, the outpatient claim is subject to retrospective review through a provider audit. 

Outpatient services rendered prior to an inpatient admission (preadmission). 

Outpatient procedures, such as preadmission services and other services related to the admission, can be before the date of the inpatient admission, but they are not separately reimbursable. Charges for outpatient services not related to the admission may be billed separately. Preadmission services include:

– Preoperative examinations. 

Services billed with a diagnosis code for preoperative examinations are not separately reimbursable. 

– Preadmission diagnostic services. 

IBC’s acute care hospital inpatient reimbursement includes payment for preadmission diagnostic services, and charges for preadmission diagnostic services must be included on the inpatient claim. Diagnostic services provided to a Member within three days prior to and including the date of the Member’s admission are deemed to be inpatient services and included in the inpatient payment. For example, if a Member is admitted on a Wednesday, outpatient services provided by the hospital on Sunday, Monday, Tuesday, or Wednesday are included in the inpatient reimbursement. 

Diagnostic services include the following revenue/procedure codes*: 

o 0254: Drugs incident to other diagnostic services 

o 0255: Drugs incident to radiology 

o 030X: Laboratory 

o 031X: Laboratory pathological 

o 032X: Radiology diagnostic 

o 0341, 0343: Nuclear medicine, diagnostic/diagnostic radiopharmaceutical

o 035X: Computed tomography (CT) scan 

o 0371: Anesthesia incident to radiology 

o 0372: Anesthesia incident to other diagnostic services 

o 040X: Other imaging services o 046X: Pulmonary function 

o 0471: Audiology diagnostic 

o 0482: Cardiology, stress test 

o 0483: Cardiology, echocardiology 

o 053X: Osteopathic services

o 061X: Magnetic resonance technology (MRT) 

o 062X: Medical/surgical supplies, incident to radiology or other diagnostic services 

o 073X: Electrocardiogram (EKG/ECG) 

o 074X: Electroencephalogram (EEG) 

o 0918: Testing, behavioral health

o 092X: Other diagnostic services

* The list of diagnostic services may be revised periodically to reflect current revenue and/or procedure codes.

– Other preadmission services. Non-diagnostic outpatient services that are related to a Member’s hospital admission during the three days immediately preceding and including the date of the Member’s admission are deemed to be inpatient services and are included in the inpatient payment. Non-diagnostic services are defined as being related to the admission when there is a match between the principal diagnosis codes (first three digits) assigned for both the preadmission services and the inpatient stay.

Inpatient hospice care 

Reimbursement is made directly to the contracted hospice agency for the provision of inpatient hospice care. The contracted hospice agency is responsible for reimbursing the hospital for the provision of general inpatient hospice care.

Present on admission (POA) indicator 

All acute care hospitals are required to follow instructions from the Centers for Medicare & Medicaid Services (CMS) regarding the identification of the POA indicator for all diagnosis codes for inpatient claims. Claims submitted without a valid POA indicator will be rejected. Consistent with the CMS requirements for POA indicators, the following facility types are exempt: 

• critical access hospitals 
• long-term care hospitals 
• cancer hospitals 
• children’s inpatient facilities 
• inpatient rehabilitation facilities 
• psychiatric hospitals 

Member enrollment during an admission 

IBC payment responsibility varies depending on the Member’s coverage, as summarized below:  Commercial HMO and PPO Members. IBC is required to cover the admission from the Member’s enrollment date in an IBC plan. If a Member enrolls in a Commercial plan from another Commercial HMO plan, the previous plan should cover the Member’s entire admission. 

Medicare Advantage HMO and PPO Members. Original Medicare covers the Member through to the discharge date.