CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPOO2

Inpatient/Outpatient Unbundling Policy - Facility

Defines facility-level unbundling, bundled routine services, incidental services, and items ineligible for separate reimbursement for Blue Cross Blue Shield of New Mexico; applies to facility providers submitting claims for inpatient and outpatient services.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyInpatient/Outpatient Unbundling Policy - Facility

Policy CodePolicy CPCPOO2

Change TypeNo material changes

Effective DateDecember 27 , 2023

Next Review DateN/A

Key ActionSubmit accurate documentation and be prepared to provide itemized statements, vendor invoices, or additional records upon request to support billed facility charges.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5.0policy version

2023-12-27effective date

2023-12-21approval date

Multipleitems/services ineligible

4implant revenue codes

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Unbundling and Non-Reimbursable Facility Charges

Facility charges that are routine, incidental, mutually exclusive, contaminated/not utilized, or part of routine bundled services are not eligible for separate reimbursement and should not be billed separately.

ALL of the following

ONE of
- Items prepared, opened, or made available but not used, contaminated, wasted, opened by mistake, or unused due to equipment failure, surgeon change of mind, or case cancellation are not eligible for reimbursement
  Examples: large packages when smaller packaging appropriate; non-utilized DME, crash carts, emergency drugs
- Disposable supplies furnished in inpatient and outpatient settings are ineligible for separate reimbursement
  Examples: syringes, needles, blood/urine testing supplies (except diabetes treatment), sheaths, bags, bandages, gauze, replacement batteries
Routine bundled services and supplies included in the general location or surgery charge (floor stock) are not separately reimbursable
Examples: drapes, saline solutions (flush/irrigation), reusable items, regular room and board components, admission/hygiene/comfort kits
Services and equipment integral to specialty care units (SCU/ICU/CCU) are included in the specialty unit/room charge and are not eligible for separate reimbursement
Examples: respiratory and cardiac monitoring equipment, respirators, defibrillators, wall or canister oxygen
Incidental services that are clinically integral to the primary procedure, including technical charges for equipment purchase, rental, or maintenance, are excluded from separate billing
Surgical suite and service charges include nursing personnel services, supplies, and equipment; many surgical items and services are included and not separately billable
Examples: reusable instruments, anesthesia equipment/monitors, electrosurgical equipment, crash carts, room set-ups
Respiratory therapy charges (including routine disposable/reusable equipment, technician time, personnel) and ventilator-related components are included in respiratory or ventilator charges and not separately reimbursable
Mutually exclusive procedures that cannot reasonably be performed together on the same member on the same day should not be billed together
BCBSNM may review claims, apply coding edits, and request supporting documentation; the plan retains discretion and defers to plan or contract terms when applicable

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Oxygen reimbursement stance

Oxygen charges are not eligible for separate reimbursement.

ALL of the following

Oxygen and water
Respiratory therapy technician time
Oxygen distribution or delivery equipment (e.g., flow meter, humidifier, croupette)
All disposable supplies associated with oxygen delivery
Examples: nasal cannula, nasal catheter, associated masks, tent or hood, T-piece, isolettes
Oxygen-related items provided as routine supplies in room/critical care charges are included and not separately billable

Ventilator charge components

Ventilator and related respiratory charges include clinical services and component items that are included in the ventilator or respiratory therapy charge.

ALL of the following

Respiratory technician services such as respiratory assessment, intubation/extubation, manual ventilation during in‑hospital transport, and endotracheal tube care
Ventilator equipment and components including Ambu ventilator machine(s), breathing circuit, IMV circuit, PEEP
Technician time, water, and disposable ventilator supplies (e.g., bags and related disposables)
Routine respiratory therapy treatments are included (aerosol, incentive spirometry, IPPB, percussion/postural drainage, ultrasonic nebulizer)

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Implant revenue code criteria

Billing for implant revenue codes 0274, 0275, 0276, and 0278 must meet documentation requirements; separate reimbursement is allowed only when supported.

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General coding requirements

General coding and billing guidance to support accurate claim submission and to avoid unbundling denials.

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Required Codes, Revenue Codes, and Claim Review

Required code sets and guidelinesmixed

HIPAA-approved code sets

Claims must use valid HIPAA-approved code combinations and follow coding guidelines (UB, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI/CCI).

Implant revenue codes requiring supporting documentationRevenueCovered

0274	Pros/Ortho devices (implant revenue code)
0275	Pacemaker (implant revenue code)
0276	Intraocular Lens (implant revenue code)
0278	Other Implants (implant revenue code)

Claim review scope

Scope of claim reviewAn itemized statement may be examined and may include review of associated medical records to identify unbundling or inappropriate charges for inpatient or outpatient claims.

Records examinedItemized statement and related medical records may be requested and reviewed during claim adjudication.

PurposeTo determine whether billed charges are separate, duplicated, or included in another billed service.

Use of unlisted codes

Permitted useUnlisted codes may be reported only if no appropriate CPT or HCPCS code exists.

Documentation requirement

Documentation, Billing Requirements, and Supporting Evidence

Documentation Required

Documentation and Claim Review

Providers are responsible for maintaining accurate and complete documentation of services performed and ensuring claims are submitted using valid HIPAA-approved code sets (e.g., UB, HCPCS, ICD-10, NDC) and in accordance with industry coding guidelines and any applicable provider contract or plan document. Claims are subject to review against benefit coverage, contract language, medical policies, clinical payment and coding policies, and coding/software edits. Upon request, providers must submit additional documentation to support services billed.

Documentation Required

Supporting documentation for implant revenue codes

When inpatient or outpatient hospital claims include Revenue Codes 0274 (Pros/Ortho devices), 0275 (Pacemaker), 0276 (Intraocular Lens), or 0278 (Other Implants) and those items are separately reimbursable, the payer may require submission of a vendor invoice that documents the supplies used for the services rendered. If supplies were purchased in bulk, the invoice must clearly note the specific units that apply to the claim. If the invoice does not document or match the units billed, the charges reported under revenue codes 0274, 0275, 0276, and 0278 may be denied unless otherwise agreed upon by BCBSNM.

Affected revenue codes: 0274, 0275, 0276, 0278

Key Terms and Examples

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.

Clinical independencePolicy does not intend to impact medical practice; providers should exercise independent medical judgment.

Mutually Exclusive Procedures

DefinitionProcedures that cannot reasonably be performed together on the same member on the same day based on code definitions or anatomic considerations.

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