Services Bundled into Inpatient / Outpatient Stays

Description

Routine services, supplies, and equipment are included within the overall room and board or room care charges of inpatient and outpatient stays.

Billed charges for hospital routine services, supplies, equipment and items constitute unbundled, fragmented or otherwise duplicative charges which should reasonably be included in another charge.

Surgical rooms include, but are not limited to, surgical suites, major and minor treatment rooms, endoscopy labs, cardiac cath labs, X-ray, pulmonary and cardiology procedural rooms.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will limit reimbursement for routine services, supplies, and equipment according to the criteria outlined in this policy. 

Reimbursement Guidelines

Routine services, supplies, and equipment are included in a daily hospital service charge and are not separately reimbursable. Routine surgical services and supplies associated with an outpatient surgical procedure are not separately reimbursable.

Any supplies, items, and services that are necessary or otherwise integral to the provision of a specific service and/or to the delivery of services in a specific location are considered routine services and not separately reimbursable in the inpatient and outpatient settings.

Non-reimbursable services may result in line-item reductions.

All items and supplies that may be purchased over-the-counter are not separately reimbursable.

Reusable items, supplies, and equipment that are provided to all patients admitted to a given treatment area or unit (i.e. NICU, Burn Unit, PACU, Medical/Surgical) are not separately reimbursable.

All reusable items, supplies, and equipment that are provided to all patients receiving the same service (i.e., an Ambu bag during resuscitation) are not separately reimbursable. The operating room (OR) charge may be based on time or on a procedural basis. It is inappropriate to include both a time based and procedural based OR fee.

Anesthesia supplies are not separately reimbursable when billed with anesthesia time-based charge.

Blue Cross NC’s inpatient reimbursement is considered all-inclusive.

Non-professional services provided to a Blue Cross NC member by an entity other than the admitting facility while the member is registered as an inpatient at an acute care hospital, long term acute care hospital, skilled nursing facility, psychiatric hospital/facility, substance abuse hospital/facility or a residential treatment center/facility are not separately billable to Blue Cross NC.

All ventilator equipment and supplies are not separately reimbursable from the ventilator charge.

The tables below are examples and do not represent an all-inclusive list:

Not Separately Reimbursable Routine Equipment

Ambu bag

Fans

Patient room furniture; manual, electric, semielectric beds

Aqua pad motor

Feeding pumps

PCA pump

Arterial pressure monitors (inclusive of Critical Care room charges only)

Flow meters

Pen light or other flashlight

Auto Syringe Pump

Footboard

PICC line (reusable equipment associated with PICC line placement)

Automatic thermometers and blood pressure machines

Glucometers

Pill pulverizer

Bed scales

Guest beds

Pressure bags or pressure infusion equipment

Bedside commode

Heating or cooling pumps

Radiant warmer

Blood pressure cuffs

Hemodynamic monitors (inclusive of Critical Care room charges only)

Sitz bath

Blood warmers

Humidifiers

Stethoscope

Cardiac monitors

Infant warmer

Suction pumps

CO2 monitors

Injections (therapeutic, prophylactic, or diagnostic)

Telephone

Crash cart

IV pumps; single and multiple lines, tubing

Televisions

Defibrillator and paddles

Nebulizers Traction equipment

Digital recording equipment and printouts

Overhead frames

Transport isolette

Dinamap

Over-bed tables

Wall suction, continuous or intermittent

Emerson pumps

Oximeter/Oxisensors – single use or continuous 

Not Separately Reimbursable Routine Services

Administration of blood or any blood product by nursing staff (does not include tubing, blood bank, preparation, etc.)

Feeding of patients

Oral care

Administration or application of any medicine, chemotherapy, and/or IV fluids.

Incontinence care

No separate charge will be allowed for callback, emergency, standby, urgent attention, ASAP, STAT, or portable fees.

Arterial and venipuncture

Injections (therapeutic, prophylactic or diagnostic)

Patient and family education and counseling

Assisting patient onto bedpan, beside commode or into bathroom

Insert, discontinue, and/or maintain nasogastric tubes

Preoperative care

Bathing of patients

Intubation

Respiratory therapy services

Bedside Glucose monitoring

Maintenance and flushing of Jtubes, PEG tubes, and feeding tubes of any kind

Set up and/or take-down of: IV pumps, flow meters, heating or cooling pumps, over-bed frames, oxygen, feeding pumps, TPN, traction equipment, monitoring equipment

Bedside tracheostomy care and changing of cannulas

Maintenance of oxygen administration equipment

Shampoo hair

Body preparation of deceased patients

Medical record documentation

Single determination or continuous pulse oximetry monitoring.

Cardiac rehabilitation (during inpatient stay)

Mixing, preparation of, or dispensing of any medication, IV fluids, total parenteral nutrition (TPN), or tube feedings

Start and/or discontinue IV lines

Cardiopulmonary resuscitation (CPR); including the management/participation in cardiopulmonary arrest event. Obtaining and recording of blood pressure, temperature, perspiration, pulse, pulse oximetry

Monitoring and maintenance of peripheral or central IV lines and sites – to include site of care, dressing changes and flushes

Suctioning or lavage of patients

Changing of dressing, bandages and/or ostomy appliances

Monitoring of cardiac monitors; CVP (central venous pressure) lines; Swan Ganz lines/pressure reading; arterial lines/readings; pulse oximeters; cardiac output, pulmonary arterial pressure.

Transporting, ambulating, range of motion, transfer to and from bed or chair

Changing of linens and patient gowns

Neurological status checks

Turning and weighing patients

Chest tube maintenances, dressing change, discontinuation

Nursing care

Urinary catheterization

Enemas Obtaining and recording vital signs (blood pressure, temperature, respiration, pulse, pulse oximetry)

Wound care (during inpatient stay)

Enterostomal services

Obtaining: Finger-stick blood sugars; blood samples from either venous sticks or any type of central line catheter or PICC line; arterial draws; urine specimens; stool specimens; sputum specimens; body fluid specimen

Not Separately Reimbursable Routine Supplies

Admission, hygiene, and or comfort kits

IV (intravenous) arm boards

Shampoo

Alcohol swabs

Lotion

Sharps container

Arterial blood gas kits

Lubricant

Shaving cream

Baby powder

Masks (patient or staff)

Skin cleansing liquid

Band-aids

Meal trays

Soap

Basin

Measuring pitcher

Socks/slippers

Bedpan, regular or fracture pan

Mid-stream urine kits

Specipan

Blood tubes

Mouth care kits

Sputum trap

Cotton balls (sterile or nonsterile)

Mouthwash

Syringes

Deodorant

Needles

Tape

Drapes

Odor eliminator/ Room deodorizer

Thermometers

Dressings and bandages

Oral swabs

Tissues

Emesis basin

Oxygen

Toilet paper

Flushes (Heparin, Saline, water, etc.)

Oxygen masks

Tongue depressors

Gloves (patient or staff)

PICC (peripherally inserted central catheter) Line

Toothbrush

Glycerin swabs

Pillows

Toothpaste

Gown (patient or staff)

Preparation kits

Tubing (IV, suction, equipment, etc.)

Heat light or heating pad

Razors

Urinal

Ice packs

Restraints

Water pitcher

Irrigation solutions

Reusable sheets, blankets, pillowcases, draw sheets, underpads, washcloths and towels

Items used to obtain a specimen or complete a diagnostic or therapeutic procedure

Saline solutions

Not Separately Reimbursable Routine Critical Care Services

Facility service charge for critical care includes the routine tables for Equipment, Services, and Supplies

Special equipment (dinemapp, swan ganz, pressure monitor, pressure transducer monitor, oximetry monitor, etc.)

Nursing Care

Telemetry

Respiratory therapy services

Not Separately Reimbursable Routine Surgical Services and Supplies

Air conditioning and filtration

Fracture tables

Robotic surgical systems

All reusable instruments charged separately

Grounding pads

Room heating/cooling and monitoring equipment

All services rendered by RN’s, LPN’s, scrub technicians, surgical assistants, orderlies, and aides

Hemochron

Room set-ups of equipment and supplies

Anesthesia equipment, supplies and monitors

Hemoconcentrator

Saline slush machine

Any automated blood pressure equipment

Hemostatic agents (Tisseel, FloSeal, etc)

Skin closure devices (sutures, staples, etc.)

Cardiac monitors

Instrument trays

Solution warmer

Cardiopulmonary bypass equipment

Laparoscopes, bronchoscopes, endoscopes, and accessories

Surgeons’ loupes or other visual assisting devices

CO2 monitors

Lights, light handles, light cords, fiber optic microscopes

Surgical clips and staplers (reloads, etc.)

Crash carts

Local Anesthesia (long or short acting)

Surgical drill

Digital recording equipment and printouts

Monopolar and bipolar electrosurgical/bovie and cautery (equipment and handpieces)

Transport monitor

Dinamap

Negative pressure wound therapy (vacuum assisted closure devices)

Video camera and tape

Disposable surgical supplies (trocars, blades, gowns, guide wires, etc.)

Obtaining laboratory specimens

Wall suction equipment

Facility service charge for surgical services includes the routine tables for Equipment, Services, and Supplies

Power equipment

X-ray film 

Flat or Per day supply fees

Reusable surgical equipment, instruments and trays

Not Separately Reimbursable Respiratory Services

Bedside pulmonary mechanics

Intubation assistance

Sleep apnea monitoring system (setup, screening and monitoring)

Chest manipulation (external chest wall oscillation)

Mini bronchoalveolar lavage test

Spontaneous breathing screen/trial

Cleaning of internal or external components of ventilator

Monitoring during transport or for special procedure

Static pressure/volume loop

Diaphragmatic EMG sensor catheter placement

Nasal cannula system

Supplemental oxygen (systemsetup, patient/systemassessment, equipment change)

End tidal carbon dioxide system-setup and/or monitoring (expired gas determination)

Oral care

Surfactant administration

Equipment change (all noninvasive and invasive) from one type of respiratory assist device to another

Oximetry check and/or trending

Therapeutic ventilatory maneuver (recruitment maneuver)

Esophageal balloon catheter placement

Placement or change of in-line suction catheter

Tracheostomy tube care 

Esophageal pressure monitoring

Positive expiratory pressure (PEP) breathing device, instruction and/or therapy

Transcutaneous monitoring (initial system setup and/or monitoring)

FRC (functional residual capacity) determination

Respiratory assessment and/or respiratory protocol assessment

Vent-acquired pneumonia prevention activities

Gas cylinder change

Respiratory therapy education

Ventilator circuit change

Heliox ventilation

Saline diluents

Ventilator transport

Incentive spirometry (set up or demonstration for patient at bedside)

Setting or device adjustment (emergent or non-emergent, invasive or non-invasive)

Ventilator weaning and extubation

Rationale

Similar to CMS and correct coding initiatives, Blue Cross NC will not separately reimburse for routine services, supplies, and equipment as they are deemed to be included in the daily hospital service charge.

Per CPT and CMS guidelines, heparin flushes (J1642), saline flushes (A4216), IV flushes of any type, and solutions used to dilute or administer substances, drugs, or medications are included in the administration service. These items are considered supplies and are not eligible for separate reimbursement. Although J1642 (Injection, heparin sodium, (heparin lock flush), per 10 units) describes heparin flushes, heparin flushes are not considered a “drug” and are not separately reimbursable.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com .

Related policy

Bundling Guidelines

References

Blue Cross NC Provider Manual Provider Blue Book

CMS Provider Reimbursement Manual, Determination of Cost of Services to Beneficiaries, Chapter 22, Section 2202.6 

History

6/9/2021 Content extracted from provider manual and developed into policy to clarify and summarize routine services, supplies, and equipment included in a daily hospital service charge. Blue Cross Blue Shield North Carolina (Blue Cross NC) will limit reimbursement for routine services, supplies, and equipment according to the criteria outlined in this policy. Notification on 6/9/2021 for effective date 8/10/2021 (eel)

9/21/2021 Removed ventilator management items from Critical Care and Respiratory grids. (eel)

12/30/2021 Routine policy review. Medical Director approved. Based on existing provider manual language, “Cardiac rehabilitation (during inpatient stay)” added to routine service list. (eel)

12/31/2022 Routine policy review. Added clarifying language about line-items reductions under Reimbursement Guidelines. Medical Director approved. (cjw)

4/21/2023 Added verbiage to Reimbursement guidelines section to clarify inpatient reimbursement being considered all-inclusive. Clarified Rationale section. MD Approved. Notification on 4/21/2023 for effective date 6/30/2023. (eel)

6/30/2023 Clarification added to Routine Surgical grid “Skin closure devices” and “Surgical Clips and Staplers“. Clarification added to Routine Respiratory “PEP instruction and/or therapy”. No change to policy intent. (eel)

10/12/2023 Respiratory therapy services added to Not Separately Reimbursable Routine Services table. Nursing care added to Not Separately Reimbursable Routine Critical Care Services table. Medical Director approved. Notification on 8/1/2023 for effective date 10/12/2023. (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.