CurrentAmerigroupPolicy G-01017

Preadmission Services for Inpatient Stays

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Defines Amerigroup's reimbursement stance for outpatient services provided prior to an inpatient hospital admission (the payment window), including which services are included or excluded and billing considerations; applies to providers billing Amerigroup for inpatient-related preadmission services.

Policy Summary

PayerAmerigroup

PolicyPreadmission Services for Inpatient Stays

Policy CodePolicy G-01017

Change TypeNo material change

Effective DateSep 11, 2025

Last ReviewSep 11, 2025

Next Review Date

Key ActionEnsure preadmission services meet authorization and medical necessity guidelines and code appropriately to avoid denial or recoupment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-daypayment window for admitting hospitals (prior to and including day of admission)

1-daypayment window for specialty hospitals/units (prior to and including day of admission)

Not includedCAH preadmission services reimbursed separately

Examples listedServices excluded from payment window (examples)

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CurrentAmerigroupPolicy G-01017

Preadmission Services for Inpatient Stays

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Policy Summary

PayerAmerigroup

PolicyPreadmission Services for Inpatient Stays

Policy CodePolicy G-01017

Change TypeNo material change

Effective DateSep 11, 2025

Last ReviewSep 11, 2025

Next Review Date

Key ActionEnsure preadmission services meet authorization and medical necessity guidelines and code appropriately to avoid denial or recoupment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-daypayment window for admitting hospitals (prior to and including day of admission)

1-daypayment window for specialty hospitals/units (prior to and including day of admission)

Not includedCAH preadmission services reimbursed separately

Examples listedServices excluded from payment window (examples)

Preadmission Service Coverage Criteria

Coverage criteria for preadmission services

Reimbursement determinations for preadmission services follow CMS-based payment windows and specified exceptions.

Preadmission services reimbursement follows CMS-based payment windows as specified below; services are included in inpatient reimbursement within the applicable window and are not separately payable unless an exception applies.

Billing Indicators and Coding Guidance

Billing indicators for related/unrelated servicesmixed

Condition Code 51	Attestation that outpatient non-diagnostic service is unrelated to the inpatient admission and billed separately
Modifier PD	Indicates service is related to the inpatient admission

Standard correct coding

Coding ruleApply standard correct coding; use CPT/HCPCS/revenue codes supported by the medical record.

Documentation supportMedical record must substantiate codes billed to avoid denial, recoupment, or adjustment.

Code systemsUse appropriate CPT, HCPCS, and facility revenue codes as documented in clinical records.

Authorization and Claims Adjudication

Prior Authorization

Ensure authorization, medical necessity, and supported coding

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; improper coding or failure to follow billing/submission guidelines may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement.

Use industry-standard CPT, HCPCS, and/or revenue codes that are fully supported in the medical record or office notes.
Failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection/denial, recovery/recoupment, or adjustment of payment.

Key Definitions

Admission Related Outpatient Nondiagnostic Services

DefinitionServices that are furnished in connection with the principal diagnosis assigned to the inpatient admission.

Inclusion in payment windowIf furnished within the applicable preadmission payment window, these services are generally included in inpatient reimbursement and not separately payable.

Attestation optionIf unrelated, may be billed separately when attested (see Condition Code 51).

Condition Code 51

MeaningDenotes attestation that an outpatient non-diagnostic service is unrelated to the inpatient admission and billed separately.

UsageHospitals may bill with Condition Code 51 to have unrelated outpatient nondiagnostic services considered separately payable.

Admission-related Preadmission Rules

hospital

Admission criteria for hospitals — covered when the applicable payment-window conditions are met.

ONE of

Admitting hospitals: diagnostic outpatient services and admission-related nondiagnostic outpatient services furnished within the three days prior to and including the day of the member's admission are considered part of the inpatient stay reimbursement and are not separately reimbursable.
Psychiatric hospitals/units, inpatient rehabilitation facilities/units, long-term care hospitals, children's hospitals, and cancer hospitals: diagnostic outpatient services and admission-related nondiagnostic outpatient services furnished within one day prior to and including the day of the member's admission are considered part of the inpatient stay reimbursement and are not separately reimbursable.
Critical Access Hospitals (CAH): the three-day and one-day payment windows do not apply; preadmission services are separately reimbursable from the inpatient stay reimbursement.

Discharge-related Preadmission Rules

The policy identifies specific services that are considered outside the preadmission payment window and therefore may be separately reimbursable rather than bundled into the inpatient stay. These excluded services include ambulance services, maintenance renal dialysis services, and services furnished by skilled nursing facilities, home health agencies, and hospices. Additionally, unrelated nondiagnostic services are not considered part of the payment window. Providers should bill these services separately when appropriate and supported by the medical record and applicable coding rules.

Payment Window Day Limits

Admitting hospital payment window (3-day)

Payment windowThree days prior to and including the day of admission for admitting hospitals.

ScopeIncludes entities wholly owned or operated by the admitting hospital or under arrangements with the admitting hospital.

ExceptionsDoes not apply to services included in the RHC or FQHC all-inclusive rate or to CAH facilities.

Specialty hospital/unit payment window (1-day)

Payment windowOne day prior to and including the day of admission for psychiatric hospitals/units, inpatient rehabilitation facilities/units, long-term care hospitals, children's hospitals, and cancer hospitals.

ApplicabilityThese settings follow a 1-day window and therefore preadmission services within that window are included in inpatient reimbursement.