CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP002

Inpatient/Outpatient Unbundling Policy - Facility

Defines which facility services, supplies, equipment and charges are considered routine or bundled (inpatient and outpatient) and thus ineligible for separate reimbursement; applies to in-network and out-of-network facilities billing Blue Cross Blue Shield - Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyInpatient/Outpatient Unbundling Policy - Facility

Policy CodePolicy CPCP002

Change TypeNo material change

Effective DateDec 16, 2021

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request; claims are subject to review and may be denied if third parties bill services reimbursed under an all-inclusive facility payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4major listed categories of bundled items

Manyexamples not separately reimbursable

0274-0276,0278implant revenue codes with invoice rules

In & Outnetworks covered

Bundling and Facility Responsibility

Bundling and facility responsibility

Covered when ALL of the following are met:

All services provided during a member's admission that are reimbursed under an all-inclusive payment method should be billed by the facility, not a third party; services billed by a third party during the member's admission are the facility's responsibility and may be denied.

Routine services and supplies that are integral to the provision of care or routinely available at the service location (floor stock, reusable items, routine equipment) are included in the facility charge and are ineligible for separate reimbursement; they should not be billed separately.

Items and supplies that can be purchased over-the-counter, unless otherwise specified, and all reusable items, supplies, and equipment provided to members during an inpatient or outpatient encounter (examples: drapes, saline solutions, pulse oximeter, blood pressure cuffs, bedside table) are ineligible for separate reimbursement and should not be billed separately.

Supplies, items and services that are necessary or otherwise integral to the provision of a specific service and/or the delivery of services in a specific location are considered routine bundled services and are ineligible for separate reimbursement.

Implant Revenue Codes and Invoice Requirements

Implant revenue codes with invoice requirementsRevenueCovered

0274	Pros/Ortho devices revenue code
0275	Pacemaker revenue code
0276	Intraocular lens revenue code
0278	Other implants revenue code

inv-03: Invoice unit match requirement

RequirementVendor invoice must indicate units that match billed units for revenue codes 0274, 0275, 0276, and 0278; if units do not match or are not noted, those revenue codes will be denied unless otherwise agreed upon.

Bulk purchasesIf supplies are purchased in bulk, the invoice must note the units that apply to the claim billed or revenue codes 0274, 0275, 0276, and 0278 may be denied.

Supporting documentationA vendor's invoice may be required to support supplies used that correspond to the services rendered for these implant revenue codes, unless otherwise agreed upon.

Documentation, Claim Review, and Vendor Invoice Requirements

Documentation Required

Documentation and Claim Review

Providers are responsible for submission of accurate documentation of services performed. Providers must submit claims using valid HIPAA-approved code sets and may be asked to provide additional documentation upon request. Claims are subject to review for coding edits, benefit coverage, provider contract terms, medical and clinical payment policies, and coding software logic. Upon request, the provider is urged to submit any additional documentation to support the claim.

Billing Rule

Invoice Requirement for Implant Revenue Codes (0274–0276, 0278)

For inpatient and outpatient hospital claims billed with implant revenue codes 0274, 0275, 0276, and 0278, a vendor invoice that documents the supplies used and shows matching units may be required to support separate reimbursement. The invoice must clearly indicate the units that correspond to the claim; if units are missing or do not match the billed units, the revenue codes may be denied. If supplies were purchased in bulk, the portion (units) allocated to the claim must be identified on the invoice. Additionally, revenue code 0278 should not be used to bill items that are supplies; such charges may be ineligible for separate reimbursement and may be considered unbundled.

Affected revenue codes: 0274, 0275, 0276, 0278
Vendor invoice must show units that match billed units
If supplies purchased in bulk, invoice must note units applied to claim
Revenue code 0278 should not be billed for items that are supplies; may be ineligible for separate reimbursement

Routine Services and Bundled Supplies

inv-06: Routine services

DefinitionRoutine services are those included by the provider in a daily service charge and composed of general routine service and special care units (SCU, CCU, ICU).

Typical componentsIncludes regular room, dietary services, nursing services, minor medical/surgical supplies, medical social and psychiatric social services, and use of certain equipment and facilities for which a separate charge is not applicable.

Equipment ruleEquipment commonly available or ordinarily furnished in a setting (even if rented by the hospital) is considered routine and ineligible for separate reimbursement.

Disposable suppliesDisposable supplies furnished in inpatient and outpatient settings (e.g., syringes, needles, testing supplies, sheaths, bags, bandages) are ineligible for separate reimbursement.

inv-07: Routine bundled services and supplies

Bundling ruleRoutine bundled services and supplies are included in the provider's general charge for the location or associated procedure and are ineligible for separate reimbursement.

ExamplesFloor stock items such as drapes, saline solutions (flush and irrigation), and reusable items are considered routine and should not be billed separately.

Reusable itemsAll reusable items, supplies, and equipment provided to all members during an encounter (e.g., pulse oximeter, blood pressure cuffs, bedside table) are ineligible for separate reimbursement.

OTC itemsItems that can be purchased over-the-counter may be ineligible for separate reimbursement unless otherwise specified.

inv-08: Contaminated/Not Utilized/Waste supplies

ScopeSupplies prepared or opened during a procedure but not used or implanted may not be eligible for reimbursement.

Examples of ineligible situationsItems opened by mistake; surgeon change of mind; equipment failure or technical difficulties; surgery case cancellation.

PackagingLarge packages of items, supplies, or implants where more appropriate packaging could be purchased may be considered ineligible.