CurrentBlue Cross Blue Shield - IllinoisPolicy CPCP002

Inpatient/Outpatient Unbundling (Facility)

Defines facility-level unbundling, bundled/routine items and services in inpatient and outpatient settings and describes reimbursement exclusions and billing expectations for providers submitting claims to BCBSIL.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyInpatient/Outpatient Unbundling (Facility)

Policy CodePolicy CPCP002

Change TypeNo material change

Effective DateDec 21, 2023

Next Review Date

Key ActionUpon request, submit additional documentation; claims are subject to review and may require supporting records, invoice matching, and accurate coding.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5.0policy version

12/21/2023effective date

Facilityapplies to

Manyexamples excluded/bundled

4implant revenue codes

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explicitly ineligible categories

Ineligible / Bundled Facility Items and Services

Items, services, and charges that are ineligible for separate reimbursement or considered bundled include, but are not limited to:

ALL of the following

Contaminated, Not Utilized or Waste: items prepared or opened but not used or implanted; non-utilized supplies and DME (including crash carts and emergency drugs); items opened by mistake; change of mind by the surgeon; equipment failure/technical difficulties; surgery case cancellation; large packages when smaller packaging is appropriate.
Disposable supplies furnished in inpatient and outpatient settings (examples include syringes, needles, blood or urine testing supplies except for diabetes treatment, sheaths, bags, elastic garments, stockings, bandages, garter belts, gauze, replacement batteries) are ineligible for separate reimbursement.
Routine Bundled Services and/or Supplies: supplies and services included in the provider's general charge or associated procedure charge (floor stock) and generally available to all members. Examples: drapes, saline solutions (flush and irrigation), reusable items. Routine items are not eligible for separate reimbursement.
Routine supplies, reusable items and equipment provided to all members during an inpatient or outpatient encounter (e.g., pulse oximeter, blood pressure cuffs, bedside table, reusable sheets, blankets, towels) are considered routine and ineligible for separate reimbursement.
Routine services included in daily service charges or room and board (including regular room, dietary services, nursing services, minor medical and surgical supplies, medical/social services, and use of certain equipment and facilities) are bundled and not separately payable.
Hospital basic room and critical care area daily charges (including emergency department, observation, treatment rooms, cardiac, medical, surgical, pediatric, burn, neonate level III/IV, neurological, rehabilitative, post-anesthesia/recovery, and trauma) include personal care and supplies, ancillary personnel providing nursing/technical services, equipment and respiratory supplies and services; the listed example items (admission/hygiene/comfort kits, needles, alcohol swabs, arterial blood gas kits, band-aids, basins, bedpans, blood tubes, cotton balls, drapes, emesis basins, gloves, gowns, heat lights, ice packs, irrigation solutions, shampoo, soap, socks/slippers, etc.) are not separately payable.
Surgical Rooms and Services: charges for surgical suites, treatment rooms, endoscopy labs, cath labs, procedural rooms, etc., include nursing personnel services, supplies, and equipment and the additional services/equipment listed are included in the surgical room/service charge.
Respiratory Therapy Charges: include nursing care, respiratory technician time, personnel, routine disposable and reusable equipment, supplies/items and necessary fees; oxygen and breathing treatments (aerosol, incentive spirometry, IPPB, percussion/postural drainage, ultrasonic nebulizer) are included in the respiratory therapy charge.
Oxygen Charges: oxygen and related components (oxygen, water, technician time, distribution/delivery supplies or equipment such as flow meters, humidifiers, croupette, disposable supplies, nasal cannula/catheter, masks, tent/hood, T-piece, isolettes) are not eligible for separate reimbursement.
Contingency for implants (Revenue Codes 0274-0276 and 0278): billed charges may require vendor invoices showing units that correspond to services; units must match invoice or charges may be denied. Revenue code 0278 should not be billed for items that are supplies; such billing may be ineligible as unbundled.
Coding and Billing: providers must select the CPT or HCPCS code that accurately describes the administered drug(s), service(s) or procedure(s). Use unlisted codes only when no appropriate code exists and submit supporting documentation with unlisted codes.

Facility charge and coding criteria

Facility charge and coding criteria — Coverage and billing rules for specific charge types and coding practices:

ALL of the following

Oxygen and respiratory-related charges are bundled into oxygen/respiratory therapy charges and are not eligible for separate reimbursement (see list of components included).
Implant-related revenue codes 0274, 0275, 0276, and 0278: when separately reimbursable, providers may be required to submit vendor invoices that clearly indicate units corresponding to the claim; mismatched or missing unit detail may result in denial. Bulk purchases must have units noted on the invoice for the claim units to be accepted.
Revenue code 0278 guidance: do not bill 0278 for items that are better classified as supplies; such billing may be considered unbundling and ineligible for separate reimbursement.
Coding and Billing rule: select the CPT or HCPCS code that accurately describes the service, supply or drug. Use appropriate unlisted codes only when no specific code exists; unlisted codes require supporting documentation.

Required Codes, Revenue Codes, and Claim Edits

Required code sets and guidelinesmixed

HIPAA code sets

Claims should use valid HIPAA-approved code sets and conform to industry coding guidelines (UB, AMA CPT, HCPCS, ICD-10, NDC, DRG, CMS NCCI/CCI).

Implant revenue codes with billing requirementsRevenueCovered

0274	Pros/Ortho devices (implant) revenue code
0275	Pacemaker revenue code
0276	Intraocular Lens revenue code
0278	Other Implants revenue code (should not be billed for items considered supplies)

inv-05: Code edit and claim review

Policy actionClaims are subject to code edit protocols and claim review for unbundling and inappropriate charges.

Provider responsibilitySubmit accurate documentation and use valid HIPAA-approved code sets (UB, CPT, HCPCS, ICD-10, NDC, DRG) per industry coding guidelines.

Claim review scopeReviews may include plan documents, provider contract language, medical policies, CPCPs, and coding software logic; additional documentation may be requested.

inv-06: Vendor invoice unit match

Invoice-unit match requirementVendor invoice units must be clearly indicated and match the units billed or the revenue code will be denied unless otherwise agreed upon.

When vendor invoice is required

Billing, Documentation, and Submission Requirements

Documentation Required

Documentation and claim review

Claims are subject to review including plan documents, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, the provider is urged to submit any additional documentation to support billed services.

Providers are responsible for submitting accurate documentation of services performed.
Submit claims using HIPAA-approved code sets and appropriate code combinations (CPT, HCPCS, ICD-10, NDC, UB, DRG, etc.).
Claims may be reviewed against plan benefits and provider contract terms.

Billing Rule

Coding and billing selection guidance

Select the CPT or HCPCS code that accurately describes the administered drug(s), supply, service(s), or procedure(s). Use unlisted codes only when no specific code exists; unlisted codes must be accompanied by supporting documentation explaining why no specific code applies.

Key Terms and Charge Definitions

inv-10: Charges billed that may be represented by or are included in the description of another billed service. (Unbundling)

DefinitionUnbundling occurs when charges are billed that may be represented by or are included in the description of another billed service.

ScopeApplies to covered medical and surgical services, supplies, and equipment; not all-inclusive and does not dictate clinical care.

Provider expectationProviders are expected to exercise independent medical judgment in providing care to members while billing accurately.

inv-11: Procedures that cannot reasonably be performed together or on the same member on the same day based on code definitions or anatomic considerations. (Mutually exclusive procedures)

DefinitionMutually exclusive procedures are procedures that cannot reasonably be performed together or on the same member on the same day based on code definitions or anatomic considerations.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyInpatient/Outpatient Unbundling (Facility)

Policy CodePolicy CPCP002

Change TypeNo material change

Effective DateDec 21, 2023

Next Review Date

Key ActionUpon request, submit additional documentation; claims are subject to review and may require supporting records, invoice matching, and accurate coding.

SourceLink

On This Page

Billed charges for revenue codes 0274, 0275, 0276, and 0278 may require a vendor's invoice to support supplies used that correspond to the services rendered.

Bulk purchase handlingIf supplies are purchased in bulk, the units that apply to the claim billed must be noted on the invoice or the revenue codes may be denied.

Report the most specific, accurate HIPAA-approved code available (CPT/HCPCS).
Use unlisted codes only as a last resort and submit supporting documentation with the claim.

Billing Rule

Vendor invoice requirement for implant revenue codes

Vendor invoices may be required to support billed charges for implant revenue codes 0274, 0275, 0276, and 0278. Invoices must clearly indicate the units that correspond to the billed claim; mismatched or missing units may result in denial. If supplies were purchased in bulk, the invoice must note the units that apply to the specific claim. Do not bill revenue code 0278 for items considered routine supplies; such charges may be ineligible for separate reimbursement.

Vendor invoices may be required for Revenue Codes 0274, 0275, 0276, 0278.
Invoice must clearly indicate units that match the units billed on the claim.
Bulk purchases must show units applicable to the billed claim or revenue codes may be denied.
Do not bill 0278 for items considered supplies; may be ineligible for separate reimbursement.

Billing implicationMutually exclusive procedures should not be billed together when definitions or anatomic considerations preclude concurrent performance.

Review expectationClaims including potentially mutually exclusive procedures are subject to claim review and coding edits.

inv-12: Testing performed near or at the site of a member with results that may change care. (Point-of-care testing (POC/POCT))

DefinitionPoint-of-care testing (POC/POCT): Testing performed near or at the site of a member with results that may lead to a change in the member's care.

ContextPOC testing is included in policy considerations for services and supplies and may be bundled with other services when integral to care.

Provider guidanceSelect appropriate CPT/HCPCS codes that accurately describe the POC test; use unlisted codes only when no appropriate code exists and provide supporting documentation.

inv-13: Ventilator charges — Ventilator charges include respiratory technician services (assessment, intubation/extubation), manual ventilation during transport, endo...

Components includedVentilator charges include respiratory assessment, intubation/extubation, manual ventilation during transport, endotracheal tube care, Ambu bag, ventilator machines, breathing circuit, IMV circuit, PEEP, technician time, water, and disposable ventilator supplies.

Service inclusionRespiratory technician services and related components are considered part of ventilator charges and not eligible for separate reimbursement when included in ventilator billing.

Claim reviewVentilator-related charges are subject to review to determine appropriate billing and bundling under facility charges.

inv-14: Oxygen charges — Oxygen charges include oxygen, water, respiratory therapy technician time, distribution/delivery supplies or equipment (flow meter, humid... ).

Components includedOxygen charges include oxygen, water, respiratory therapy technician time, distribution/delivery supplies or equipment (e.g., flow meter, humidifier, croupette), disposable supplies, nasal cannula/catheter, masks, tent/hood, T-piece, and isolette(s).

Reimbursement stanceOxygen charges are not eligible for separate reimbursement.

Bundling implicationOxygen and related components are considered bundled within facility/basic charges and should not be billed separately.