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.

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

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 CMS Chapter 22

History

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.