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.
