CurrentAnthemPolicy G-01017

Preadmission Services for Inpatient Stays

Governs how preadmission outpatient services related to inpatient admissions are reimbursed for Anthem (HealthKeepers) Virginia Medicaid products, specifying which services are included in inpatient payment windows and which may be billed separately.

Policy Summary

PayerAnthem

PolicyPreadmission Services for Inpatient Stays

Policy CodePolicy G-01017

Change TypeNo material change

Effective DateSep 11, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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

1-daypayment window for specified hospital types (prior to and including admission day)

CAH excludedCritical Access Hospitals: preadmission services separately reimbursable

Examples listedServices considered outside the payment window

Condition Code 51Attestation mechanism

Policy Summary

PayerAnthem

PolicyPreadmission Services for Inpatient Stays

Policy CodePolicy G-01017

Change TypeNo material change

Effective DateSep 11, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Preadmission reimbursement criteria

Determines inclusion of preadmission services in inpatient reimbursement based on facility type and service type.

For admitting hospitals, preadmission services that occur within the three days prior to and including the day of admission are included in the inpatient reimbursement and are not separately reimbursable.

ALL of the following

Applicable facilities
- Psychiatric hospitals and units
- Inpatient rehabilitation facilities and units
- Long-term care hospitals
- Children's hospitals
- Cancer hospitals

Critical Access Hospitals (CAH) are not subject to the 3-day or 1-day payment windows; preadmission services are separately reimbursable from the inpatient stay.

The 3-day or 1-day payment window does not apply to preadmission services included in the Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) all-inclusive rate.

Preadmission services included in inpatient reimbursement consist of all diagnostic outpatient services and admission-related outpatient nondiagnostic services.

Certain services are considered outside the payment window and may be billed separately, including: Ambulance services; Maintenance renal dialysis services; Services provided by skilled nursing facilities, home health agencies, and hospices; and unrelated nondiagnostic services.

A hospital may attest that specific nondiagnostic outpatient services are unrelated and bill them separately by adding Condition Code 51 to the outpatient nondiagnostic service.

Standard correct coding and documentation apply; services must meet applicable authorization and medical necessity guidelines.

Authorization, Medical Necessity, and Provider Responsibilities

Prior Authorization

Obtain authorization and document medical necessity

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member's state of residence. Use proper billing and submission guidelines with industry-standard CPT, HCPCS, and/or revenue codes; billed services must be fully supported in the medical record and/or office notes. Failure to follow coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, and the plan may recover or recoup payment.

Confirm authorization and medical necessity prior to billing.
Bill with appropriate CPT/HCPCS/revenue codes and retain supporting medical records/office notes.
Noncompliance may lead to claim rejection, denial, or recovery/recoupment of payment.

Key Definitions and Modifiers

inv-04: Admission Related Outpatient Nondiagnostic Services — services furnished in connection with the principal diagnosis assigned to the inpatient admission.

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

Inclusion ruleThese admission-related outpatient nondiagnostic services are included in the inpatient reimbursement when they fall within the applicable payment window (see coverage criteria).

DocumentationServices must be supported by medical record documentation linking the service to the principal diagnosis for the admission.

inv-05: Condition Code 51 — denotes attestation of unrelated outpatient non-diagnostic services.

DefinitionCondition Code 51 denotes attestation that an outpatient nondiagnostic service is unrelated to the inpatient admission.

UseWhen billed, Condition Code 51 signals the provider's attestation that the nondiagnostic outpatient service is unrelated and may be considered for separate outpatient reimbursement.

Coding standardCondition Code 51 should be applied per billing guidance and supported by medical record documentation that demonstrates lack of relation to the admission.

inv-06: Modifier PD — indicates that the service is related to the inpatient admission.

DefinitionModifier PD indicates that the service is related to the inpatient admission.

Billing implicationServices reported with modifier PD are considered related to the admission and are subject to the payment window inclusion rules (i.e., typically included in inpatient reimbursement).

DocumentationUse of modifier PD must be supported by clinical documentation linking the service to the principal diagnosis for the admission.

OpenPayer

Preadmission Services for Inpatient Stays

Preadmission Services — Inclusion in Inpatient Payment

Billing Indicators and Codes

Authorization, Medical Necessity, and Provider Responsibilities

Key Definitions and Modifiers

Condition Code 51	Denotes attestation of unrelated outpatient non-diagnostic services
Modifier PD	Indicates that the service is related to the inpatient admission