Multiple surgical procedures

When multiple outpatient surgical procedures are performed during the same date of service, Providers may bill multiple outpatient surgical procedures with multiple surgical revenue codes. IBC will reimburse the primary procedure at 100 percent of the contracted rate and each eligible secondary procedure at 50 percent of the contracted rate. The primary service on each claim will be determined based on the highestallowable contracted rate. When a claim has multiple procedures with the same highest-allowable contracted rate, the first listed procedure with the highest allowable will be reimbursed as primary, all other eligible procedures will be reimbursed as secondary

Incidental procedures

 Services identified as incidental procedures (IP) on the Outpatient Fee Schedule may or may not be eligible for reimbursement. When multiple surgical procedures are performed on the same date of service, procedures identified as IP are considered incidental to the primary procedure and are not eligible for additional reimbursement. However, payment for an IP is made when that procedure is the only surgical procedure performed or when it is the primary procedure for the episode of care.

Members may not be balance-billed for any incidental procedure that is not reimbursed by IBC

Surgical procedures not found on the Outpatient Fee Schedule

Surgical procedures not listed on the Outpatient Fee Schedule are individually reviewed for payment consideration when performed in a hospital outpatient setting. IBC may also request medical records to help determine a reimbursement rate or to ensure that the procedure code reported accurately represents the surgery performed. If medical records are requested, IBC will make a determination regarding reimbursement once the documentation is received.

Variations before and after surgery

Preapproval by IBC is based on the code for the procedure planned, but the code assigned for billing after the procedure may be different. Assuming the codes are reasonably related, this is not a barrier for payment; however, an updated Preapproval/Precertification may be required.

Cancelled surgeries

Currently, three types of outpatient cancelled surgery scenarios are eligible for reimbursement. In order for these claims to be processed correctly, certain coding and billing criteria must be met. Claims submitted that do not meet these criteria will be returned to the facility for correction. Please note the criteria for each of the following scenarios when coding and billing your claims.

Scenario 1: Patient receives preoperative services, but surgery is cancelled. 

Example: The patient has preadmission testing for intended cataract surgery but subsequently develops a cold and the surgery is cancelled.

Coding and billing requirements: 

 Report the principal diagnosis code, which is the reason for the surgery. 

 Report the secondary diagnosis with the appropriate diagnosis code(s) indicating cancelled surgery.  Report the HCPCS and/or CPT code(s) for the preoperative services, indicating procedures performed and the date(s) of service. 

 Submit the claim through the standard channels — no medical record review is required. Reimbursement: The hospital will be reimbursed for preoperative services according to its Agreement. 

Scenario 2: Planned surgery is stopped before the entire procedure is completed. 

Example: The patient has planned a laparoscopic adhesiolysis. Surgery proceeds as far as the insertion of the laparoscope when the patient develops an arrhythmia and the surgery is stopped. Coding and billing requirements: 

 Report the principal diagnosis code, which is the reason for the surgery. 

 There is no need to use a diagnosis code indicating cancelled surgery.

 Code the procedure to the extent it was completed. In this example, the diagnostic laparoscopy code would be used to describe the insertion of the scope. 

 Submit the claim through the standard channels — no medical record review is required. Reimbursement: The hospital will be reimbursed to the extent that the procedure was performed (e.g., diagnostic laparoscopy) according to its Agreement.

Scenario 3: Patient was admitted to same day surgery/short procedure unit, but surgery was cancelled before it began. 

Example: Some services related to the intended procedure have been rendered. For example, the patient is in the operating room. When anesthesia has been induced, the patient’s blood pressure drops and the procedure is cancelled. 

Coding and billing requirements: 

 Report the principal diagnosis code, which is the reason for the surgery. 

 Report the secondary diagnosis with the appropriate code indicating cancelled surgery. 

 Report the HCPCS and/or CPT code for the intended procedure with the correct revenue code for outpatient surgery. 

 Submit the claim to your Network Coordinator with medical records for the encounter and the reasons for the cancellation. Claims submitted without this required information will not be considered for payment. 

Reimbursement: The hospital/facility may be reimbursed for surgical procedures cancelled for reasons beyond the hospital’s control. The hospital will be reimbursed at the minor surgery rate (surgical category M) for fee schedule claims or according to their Agreement for all other claims. The procedure will not be reimbursed if the cancellation is due to administrative reasons (e.g., equipment failure, staffing problems).

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.

If the Member’s benefits plan or regulations conflict with these provisions, actual payments may vary.

Member termination during an admission 

IBC payment responsibility varies depending on Member coverage and provider payment methodology, as summarized below: 

Payment methodology	Line of business
	Commercial HMO and Medicare Advantage HMO/PPO	Commercial PPO
Per diem	Pays to the discharge date	Pays to the last covered day
Per case	Pays the entire case rate	Pays the entire case rate
Percent of charge	Pays to the discharge date	Pays to the last covered day

If the Member’s benefits plan or regulations conflict with these provisions, actual payments may vary

Maternity admissions 

Reimbursement for maternity admissions is inclusive of the mother and newborn days while the mother is inpatient. Neonatal intensive care unit (NICU) and transitional nursery days are paid separately regardless of mother’s status as inpatient. 

 Normal delivery claims. When billing newborn baby charges (e.g., revenue code 0170, 0171, 0172, or 0179) the maternity charges for mother and baby must be combined on the same UB-04 form. NICU charges should also be added to the mother’s inpatient bill using revenue code 0173 or 0174. 

 Detained baby claims. If the baby remains hospitalized after the mother is discharged (i.e., detained baby), a new admission with its own Preapproval is required. The detained baby’s admission date is the same date as the mother’s discharge date. A separate claim for the detained baby’s admission is required. 

 For Members with Federal Employee Program (FEP) coverage. In those cases where the baby requires a higher level of care and is considered sick while the mother is still hospitalized, a separate admission for the baby is needed. The baby’s admission requires its own Preapproval. The baby’s claim is to be billed using either revenue code 0173 or 0174, and the admission date is the same as the Preapproval date.

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. 

Billing & Reimbursement for Hospital Services

Inpatient Services

The purpose of this section is to communicate specific billing requirements and reimbursement policies for inpatient hospital services. Hospitals will be reimbursed for inpatient services according to the terms of their Agreement. To the extent that any of the requirements or policies in this section conflict with the Agreement, the terms of the Agreement shall govern.

Inpatient claims 

Preapproval 

Preapproval is required for certain services prior to services being performed, including elective inpatient admissions. For detailed information on Preapproval, please refer to the Care Management and Coordination section of this manual.

 Inpatient day

 An inpatient day is an admission period that begins at midnight on the day of admission and ends 24 hours later. The midnight-to-midnight method is to be used in reporting inpatient days even if the hospital uses a different definition for other purposes. Any part of an inpatient day, including the day of admission, counts as an inpatient day. The day of discharge is not counted as an inpatient day. Inpatient services 

Inpatient services are Covered Services that are diagnostic, therapeutic, or surgical and pursuant to an admission. Reimbursement for inpatient services includes, but is not limited to: 

ancillary services 

anesthesia care 

appliances and equipment

diagnostic services 

 medication and supplies 

nursing care 

 radiology 

 recovery room services

 room and board

surgical procedures (including implantable devices, blood, and blood products) 

therapeutic items (drugs and biologicals) 

The reimbursement rates for inpatient acute admissions are inclusive of all services provided to the Member during the admission. The rate of payment is determined by the effective date of a Member’s inpatient admission and applies for the length of the admission; therefore, any rate change under the contract during the Member’s stay will not apply.

Per case reimbursed admissions only

All inpatient days that are reimbursed under a diagnosis-related group (DRG) and/or per-case payment rate are subject to Medical Necessity review, which may include concurrent review and/or retrospective review. Admissions that have been preapproved will not be retrospectively denied for Medical Necessity unless the Preapproval was based on erroneous information or misinformation provided by the hospital. 

Readmissions 

Readmissions are subject to the Inpatient Hospital Readmission policy, which applies to hospitals and health systems paid per case or per admission for inpatient hospital stays. For additional information on readmissions, please refer to our medical policies at www.ibx.com/medpolicy. 

Ungroupable or invalid DRG 

Claims that are ungroupable or group to an invalid DRG will be denied payment. Claims may be resubmitted by the hospital with corrected data.

Version DRG versus rate effective date 

Unless otherwise specified in the contract, the grouper version used will be based on the contracted version in effect on the date of admission. For all hospitals, the CMS Pricer adjustment factor applied to the DRG pricing will be based on the date of admission. 

Per-diem reimbursed admissions only 

All inpatient days that are reimbursed under a per diem payment rate are subject to a concurrent review of Medical Necessity. In the event the hospital fails to provide timely medical information necessary for concurrent review as requested by IBC, inpatient days not reviewed concurrently will be reviewed retrospectively for Medical Necessity. Admissions that have been concurrently reviewed will not be retrospectively denied for Medical Necessity unless the concurrent review was based on erroneous information or misinformation provided by the hospital.

Revenue code groupings 

Per diem reimbursement shall be based on bed-type in accordance with the following crosswalk. To the extent that any of the following revenue codes conflict with the Agreement, the terms of the Agreement shall govern.

Group	Revenue codes
Medical/surgical	0110, 0111, 0112, 0117, 0120, 0121, 0122, 0127, 0130-0132, 0134, 0137, 0140-0142, 0150-0152, 0157, 0206, 0214
Medical/surgical/pediatric	0113, 0123, 0133, 0143, 0153
Intensive care	0200-0203, 0207-0213, 0219
Sub-acute	0159, 0190-0194, 0199
Maternity/NICU	0170-0174, 0179
General rehab (non-behavioral health)	0118, 0128, 0138, 0148, 0158
Behavioral health	0114, 0116, 0118, 0124, 0126, 0128, 0134, 0136, 0138, 0144, 0146, 0148, 0154, 0156, 0158, 0204

Surgical procedures not found on the Outpatient Fee Schedule

Surgical procedures not listed on the Outpatient Fee Schedule are individually reviewed for payment consideration when performed in a hospital outpatient setting. IBC may also request medical records to help determine a reimbursement rate or to ensure that the procedure code reported accurately represents the surgery performed. If medical records are requested, IBC will make a determination regarding reimbursement once the documentation is received.

Variations before and after surgery 

Preapproval by IBC is based on the code for the procedure planned, but the code assigned for billing after the procedure may be different. Assuming the codes are reasonably related, this is not a barrier for payment; however, an updated Preapproval/Precertification may be required. 

Cancelled surgeries 

Currently, three types of outpatient cancelled surgery scenarios are eligible for reimbursement. In order for these claims to be processed correctly, certain coding and billing criteria must be met. Claims submitted that do not meet these criteria will be returned to the facility for correction. Please note the criteria for each of the following scenarios when coding and billing your claims 

Scenario 1: Patient receives preoperative services, but surgery is cancelled.

Example: The patient has preadmission testing for intended cataract surgery but subsequently develops a cold and the surgery is cancelled. 

Coding and billing requirements: 

• Report the principal diagnosis code, which is the reason for the surgery. 
• Report the secondary diagnosis with the appropriate diagnosis code(s) indicating cancelled surgery.  
• Report the HCPCS and/or CPT code(s) for the preoperative services, indicating procedures performed and the date(s) of service. 
• Submit the claim through the standard channels — no medical record review is required. 

Reimbursement: The hospital will be reimbursed for preoperative services according to its Agreement. 

Scenario 2: Planned surgery is stopped before the entire procedure is completed. 

Example: The patient has planned a laparoscopic adhesiolysis. Surgery proceeds as far as the insertion of the laparoscope when the patient develops an arrhythmia and the surgery is stopped.

Coding and billing requirements: 

• Report the principal diagnosis code, which is the reason for the surgery. 
• There is no need to use a diagnosis code indicating cancelled surgery. 
• Code the procedure to the extent it was completed. In this example, the diagnostic laparoscopy code would be used to describe the insertion of the scope. 
• Submit the claim through the standard channels — no medical record review is required.

Reimbursement:  The hospital will be reimbursed to the extent that the procedure was performed (e.g., diagnostic laparoscopy) according to its Agreement.

Scenario 3: Patient was admitted to same day surgery/short procedure unit, but surgery was cancelled before it began.

Example: Some services related to the intended procedure have been rendered. For example, the patient is in the operating room. When anesthesia has been induced, the patient’s blood pressure drops and the procedure is cancelled.

Coding and billing requirements: 

• Report the principal diagnosis code, which is the reason for the surgery. 
• Report the secondary diagnosis with the appropriate code indicating cancelled surgery. 
• Report the HCPCS and/or CPT code for the intended procedure with the correct revenue code for outpatient surgery. 
• Submit the claim to your Network Coordinator with medical records for the encounter and the reasons for the cancellation. Claims submitted without this required information will not be considered for payment

Reimbursement:  The hospital/facility may be reimbursed for surgical procedures cancelled for reasons beyond the hospital’s control. The hospital will be reimbursed at the minor surgery rate (surgical category M) for fee schedule claims or according to their Agreement for all other claims. The procedure will not be reimbursed if the cancellation is due to administrative reasons (e.g., equipment failure, staffing problems).

Laboratory services

Members are required to obtain a Physician order for laboratory services. Reimbursement for laboratory services is a global (i.e., technical and professional component) payment for services rendered. Payment is made directly to the facility according to the hospital’s contracted rates (if there is no separate designated laboratory agreement).

Capitated laboratory services 

Laboratory services for HMO/POS Members are generally provided by the designated Provider under the Capitated Laboratory Program. A complete listing of the services included in this program can be found at www.ibx.com/medpolicy. Laboratory services that are excluded from capitation are paid at the hospital’s contracted rate.

STAT laboratory services for HMO/POS Members 

If an HMO/POS Member receives STAT laboratory services from their capitated laboratory Provider, these services are included in the capitated laboratory payment and are not separately reimbursed. However, if the HMO/POS Member is not at their capitated site for STAT laboratory services, payment for the STAT testing will be reimbursed according to the hospital contracted rates. A Referral is not required for any STAT laboratory services

Observation services 

Observation services are considered an outpatient service, and involve the use of a bed and periodic monitoring by the facility’s nursing or other ancillary staff in order to evaluate and treat an individual’s condition or determine the need for a possible inpatient admission. 

Outpatient surgery 

Outpatient surgery reimbursement represents an all-inclusive payment for all facility Covered Services provided during and related to the surgical procedure. The all-inclusive payment includes services/items provided in conjunction with surgical procedures but excludes certain implantable devices. Please refer to the Outpatient Implantable Devices section on page 7.11 for more information. 

All services related to the outpatient surgery should be billed on the same claim. Surgeries performed on multiple dates should be billed on separate claims for each surgical date of service and include all of the services related to each surgery. Do not bill multiple surgical dates of service on the same claim. 

Outpatient surgical procedures are assigned a surgical category, which determines the level of reimbursement. Surgical procedures not listed on the Outpatient Fee Schedule are individually reviewed for payment consideration when performed in a hospital outpatient setting.

Services included in reimbursement for outpatient surgery 

Outpatient services rendered prior to an outpatient surgical procedure. Outpatient procedures, such as preadmission diagnostic services and other services related to the surgical procedure, can occur before the date of the surgical procedure but are not separately reimbursable.

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

Preadmission diagnostic services. Reimbursement for outpatient surgical procedures includes payment for preadmission diagnostic services. Charges for preadmission diagnostic services must be included on the surgical claim. Diagnostic services provided to a Member within 30 days prior to and including the date of the Member’s surgery are included in the surgical procedure payment. Diagnostic services include the following revenue/procedure codes*: 

– 0254: Drugs incident to other diagnostic services 

– 0255: Drugs incident to radiology 

– 030X: Laboratory

– 031X: Laboratory pathological

– 032X: Radiology diagnostic

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

– 035X: Computed topography (CT) scan 

– 0371: Anesthesia incident to radiology 

– 0372: Anesthesia incident to other diagnostic services 

– 040X: Other imaging services 

– 046X: Pulmonary function 

– 0471: Audiology diagnostic 

– 0482: Cardiology, stress test 

– 0483: Cardiology, echocardiology

– 053X: Osteopathic services 

– 061X: Magnetic resonance technology (MRT) 

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

– 073X: Electrocardiogram (EKG/ECG) 

– 074X: Electroencephalogram (EEG) 

– 0918: Testing, behavioral health 

– 092X: Other diagnostic services

 Observation services. When Outpatient surgical claims are paid according to the fee schedule, there is no additional reimbursement for observation room services

Multiple surgical procedures 

When multiple outpatient surgical procedures are performed during the same date of service, Providers may bill multiple outpatient surgical procedures with multiple surgical revenue codes. IBC will reimburse the primary procedure at 100 percent of the contracted rate and each eligible secondary procedure at 50 percent of the contracted rate. The primary service on each claim will be determined based on the highestallowable contracted rate. When a claim has multiple procedures with the same highest-allowable contracted rate, the first listed procedure with the highest allowable will be reimbursed as primary, all other eligible procedures will be reimbursed as secondary.

Incidental procedures 

Services identified as incidental procedures (IP) on the Outpatient Fee Schedule may or may not be eligible for reimbursement. When multiple surgical procedures are performed on the same date of service, procedures identified as IP are considered incidental to the primary procedure and are not eligible for additional reimbursement. However, payment for an IP is made when that procedure is the only surgical procedure performed or when it is the primary procedure for the episode of care.

Outpatient Services

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. 

Reimbursement for ER services when billed with surgical services

Services billed together - Surgical services performed in the operating room and emergency services performed in the ER

Services reimbursed* - Both ER services and surgical services are reimbursed

Revenue code requirements - Surgical services reported with 36x, 481, 49x, or 790; ER services reported with 45x

Services billed together - Surgical services and emergency services performed in the ER

Services reimbursed* - ER services are reimbursed

Revenue code requirements - Surgical services reported with 45x; ER services reported with 45x

Observation services 

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

Maternity admissions

Reimbursement for maternity admissions is inclusive of the mother and newborn days while the mother is inpatient. Neonatal intensive care unit (NICU) and transitional nursery days are paid separately regardless of mother’s status as inpatient.

Normal delivery claims. When billing newborn baby charges (e.g., revenue code 0170, 0171, 0172, or 0179) the maternity charges for mother and baby must be combined on the same UB-04 form. NICU charges should also be added to the mother’s inpatient bill using revenue code 0173 or 0174. 

Detained baby claims. If the baby remains hospitalized after the mother is discharged (i.e., detained baby), a new admission with its own Preapproval is required. The detained baby’s admission date is the same date as the mother’s discharge date. A separate claim for the detained baby’s admission is required. 

For Members with Federal Employee Program (FEP) coverage. In those cases where the baby requires a higher level of care and is considered sick while the mother is still hospitalized, a separate admission for the baby is needed. The baby’s admission requires its own Preapproval. The baby’s claim is to be billed using either revenue code 0173 or 0174, and the admission date is the same as the Preapproval date.

Per case reimbursed admissions only

All inpatient days that are reimbursed under a diagnosis-related group (DRG) and/or per-case payment rate are subject to Medical Necessity review, which may include concurrent review and/or retrospective review. Admissions that have been preapproved will not be retrospectively denied for Medical Necessity unless the Preapproval was based on erroneous information or misinformation provided by the hospital.

Readmissions 

Readmissions are subject to the Inpatient Hospital Readmission policy, which applies to hospitals and health systems paid per case or per admission for inpatient hospital stays. For additional information on readmissions, please refer to our medical policies at www.ibx.com/medpolicy. 

Ungroupable or invalid DRG 

Claims that are ungroupable or group to an invalid DRG will be denied payment. Claims may be resubmitted by the hospital with corrected data. 

Version DRG versus rate effective date 

Unless otherwise specified in the contract, the grouper version used will be based on the contracted version in effect on the date of admission. For all hospitals, the CMS Pricer adjustment factor applied to the DRG pricing will be based on the date of admission. 

Per-diem reimbursed admissions only 

All inpatient days that are reimbursed under a per diem payment rate are subject to a concurrent review of Medical Necessity. In the event the hospital fails to provide timely medical information necessary for concurrent review as requested by IBC, inpatient days not reviewed concurrently will be reviewed retrospectively for Medical Necessity. Admissions that have been concurrently reviewed will not be retrospectively denied for Medical Necessity unless the concurrent review was based on erroneous information or misinformation provided by the hospital. 

Revenue code groupings

Per diem reimbursement shall be based on bed-type in accordance with the following crosswalk. To the extent that any of the following revenue codes conflict with the Agreement, the terms of the Agreement shall govern.

Group - Medical/surgical

Revenue codes - 0110, 0111, 0112, 0117, 0120, 0121, 0122, 0127, 0130-0132, 0134, 0137, 0140-0142, 0150-0152, 0157, 0206, 0214  

Group - Medical/surgical/pediatric

Revenue codes -0113, 0123, 0133, 0143, 0153

Group - Intensive care

Revenue codes - 0200-0203, 0207-0213, 0219

Group - Sub-acute 

Revenue codes - 0159, 0190-0194, 0199

Group - Maternity/NICU

Revenue codes - 0170-0174, 0179

Group - General rehab (non-behavioral health)

Revenue codes - 0118, 0128, 0138, 0148, 0158

Group - Behavioral health

Revenue codes - 0114, 0116, 0118, 0124, 0126, 0128, 0134, 0136, 0138, 0144, 0146, 0148, 0154, 0156, 0158, 0204 

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.