Outpatient Services

The purpose of this section is to communicate specific billing requirements and reimbursement policies for outpatient hospital services

Hospitals will be reimbursed for outpatient services according to the terms of their Agreement. To the extent any of the below requirements or policies conflict with the Agreement, the terms of the Agreement shall govern. Please refer to the current Correlation Edits for Outpatient Claims, which is updated and distributed each quarter, when determining which revenue codes and HCPCS and/or CPT® codes to use for billing

Cardiology

The technical components for outpatient cardiology services are paid at the hospital’s contracted outpatient rate, with the exception of the following EKG procedure codes: 93000, 93005. These procedure codes are paid as a global reimbursement for technical and professional service components for HMO Members, and the hospital is responsible for reimbursing the Physician for their professional services.

Diabetic education

Outpatient diabetic education is a covered benefit for eligible Members who have been diagnosed as having diabetes mellitus and have a written Physician order to attend an outpatient diabetic education program. In order for a participating hospital’s program to be eligible as an approved outpatient diabetic education program in the IBC network, the program must be certified by the American Diabetes Association (ADA) and specifically referenced in the Agreement

When billing for diabetic education, use revenue code 0942, include the HCPCS and/or CPT code(s), the number of units, and a diabetic diagnosis on the UB-04 form. For billing and reimbursement purposes, one unit is equal to one visit (individual or group session).

Emergency services

Reimbursement rates for emergency services are inclusive of all services provided to the Member during the visit, including the professional component of laboratory and radiology for all managed care Benefits Programs. Fee schedule payments for Traditional (Indemnity) Members apply only for facility services.

How to bill for emergency services

Whenever one of the revenue codes in the 045X series is present, the UB-04 admitting diagnosis and the Member’s reason for the visit are required fields for outpatient claims. Please report one diagnosis code describing the Member’s stated reason for seeking care. Emergency room/department (ER) claims that do not have the required information completed will not be processed.

Critical care 

Critical care in the ER is to be billed with procedure code 99291 (i.e., critical care). Please note that procedure code 99292 is not separately reimbursable. When ER level-of-service procedure codes are billed with 99291, the claim will be paid at the lower level of service.

Follow-up care 

Routine (non-emergent) follow-up care provided in the ER setting by a Participating Provider is not a covered benefit and is not eligible for a separate ER visit payment. Claims billed for routine (nonemergent) follow-up care provided in the ER setting that contain a routine follow-up diagnosis code will be automatically denied.

When follow-up care provided in the ER setting is denied as a noncovered service, commercial Members may be billed for such noncovered services. In order to bill Members for these services, you must provide the Member with prior written notice indicating that follow-up care in the ER setting is not covered and that they will be financially responsible for any follow-up care given in the ER setting

Inpatient admissions

If the ER visit results in an inpatient admission, the date the Physician wrote the order becomes the date of admission. The ER charges should be included on the inpatient claim, and no separate ER claim should be filed.

Surgical procedures

If an ER visit includes surgery performed in a fully equipped and staffed operating room, the facility will receive fee schedule reimbursement for the ER and for the surgery. Otherwise, the surgical services are included in the reimbursement for the ER visit. The surgery should be billed using the appropriate surgery revenue and HCPCS and/or CPT codes.

When surgical services are performed in the ER and not a fully equipped operating room, those surgical services should be reported with the applicable ER revenue codes.

Observation services 

If an ER visit includes observation services, observation services may be eligible for separate reimbursement at the hospital’s contracted rate