CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Inpatient Non-Reimbursable Charge/Unbundling Policy

Defines facility charges, supplies and services that Blue Cross Blue Shield of South Carolina will not reimburse separately for inpatient and related settings and instructs providers that such items should be included in overall room/setting charges; applies to providers/facilities billing the Plan.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyInpatient Non-Reimbursable Charge/Unbundling Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOctober 1, 2018

Next Review DateN/A

Key ActionAdjust claims to remove charges determined to be unbundled, duplicated or otherwise included in another billed charge and base benefit determinations on the member's Benefit Contract Language.

SourceLink

3 tablesTables of non‑reimbursable items

A–H + L/DRoom/setting charge definitions

2018-10-01Effective date

Contract-basedBenefit determinations

Highest per 24hRespiratory rule

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Contrast allowedRadiology exception

Included / Non‑Reimbursable Inpatient Charges

Non‑reimbursable inpatient charges by setting

Items, services and personnel listed for each inpatient setting are included in that setting's overall charge and are not reimbursable if billed separately.

Room and Board/Room Care: room, dietary services, all nursing care, personnel, and routine disposable and/or reusable equipment, supplies and items appropriate for the setting (illustrative items include furniture, linens, basic supplies, thermometers, BP cuffs, gloves, gowns, masks, immobilizers taken home by patient are separately billable).

Intensive Specialty Unit/ Specialty Unit: room, dietary services, all nursing care, personnel, and routine disposable and/or reusable equipment and supplies appropriate for the specialty unit (includes monitoring or suctioning equipment, monitor pads, oximetry/oxisensors, oxygen and supplies, telemetry, incubators/isolette, crash cart).

Operating Room: all nursing care, personnel, and routine disposable and/or reusable equipment, supplies and items appropriate for the operating room (illustrative items include operating table, mayo stands, monitors, cautery/Bovie, suction machines and supplies, irrigation solutions (additives allowed separately), gowns, gloves, masks, drapes, instruments, Ambu and crash cart); instruments included in a surgical pack billed individually are not separately reimbursable (additional medically necessary items may be billed).

Anesthesia: all non-physician personnel, nursing care, inhalation anesthetic gases, and routine disposable and/or reusable equipment and supplies appropriate for anesthesia services (includes airway/breathing circuit, endotracheal tube, anesthesia machine, oxygen and supplies, syringes/needles, suction, thermometers).

Recovery Room: all nursing care, personnel, and routine disposable and/or reusable equipment, supplies and items appropriate for the recovery setting (illustrative items include airways, masks, face tents, monitors and accessories, oxygen and delivery equipment, suction equipment, blankets, warming covers, additional personnel and call back time).

Labor and Delivery: all nursing care, personnel, and routine disposable and/or reusable equipment, supplies and items appropriate for labor and delivery (illustrative items include blood pressure cuff, thermometers, monitors, oxygen supplies, betadine, 4x4 pads, gloves, lubricant, amnihook, cord clamp, drapes, sutures, name bands, suction bulbs, instruments, gowns, irrigation solutions, OB pack, Ambu bag and crash cart).

Bundled charge criteria

Items and services listed in each departmental charge definition are considered included in that departmental charge and are not reimbursable if billed separately from that charge, except where specifically noted.

Recovery Room charge includes: airways, masks, face tents, monitors and accessories, oxygen and supplies, oxygen delivery equipment, suction equipment, blankets, warming covers, additional personnel charges, call back time, and all nursing care.

Labor and Delivery charge includes: blood pressure cuff, thermometer, monitors, oxygen supplies, betadine, 4x4 pads, ink pads, gloves, lubricant, amnihook, cord clamp, drapes, sutures, name bands, foot printer, suction bulbs, instruments, gowns, irrigation solutions, OB pack, Ambu bag, crash cart, and all nursing care.

Blood charge includes: the blood itself, all blood products, related nursing care and administration, personnel, routine disposable and reusable equipment, supplies and items, and fees necessary to obtain, handle, process, store, test and administer blood.

Laboratory charge includes: all disposable supplies and collection devices, stat and call back charges, venipuncture performed by nursing staff (excluding bedside glucose), arterial punctures (unless performed by respiratory), personnel associated with specimen collection, and fees necessary to complete the laboratory procedure.

Code Guidance and Special Billing Rules

Included items by settingmixed

Lists items and supplies included within Room and Board/Room Care, Intensive Specialty Unit, and Operating Room charges (furniture, linens, monitoring/suctioning equipment, oxygen and supplies, routine disposable and reusable equipment, instruments included in surgical packs, nursing care and personnel) — not reimbursable if billed separately.

Venipuncture reimbursementmixedCovered

A venipuncture performed by laboratory personnel (not nursing staff) is reimbursable as a covered service; venipuncture performed by nursing staff is included in the Laboratory or room charge and is not separately reimbursable (excluding bedside glucoses).

Radiology contrast exceptionmixedCovered

IV and oral contrast may be billed separately from the Radiology charge (radiology charge otherwise includes nursing care, personnel, routine/scout films, stat and call back charges).

inv-06: Respiratory support per 24 hours

RuleWhen more than one level of respiratory/ventilation support occurs within the same 24-hour period, only the highest level of respiratory support will be allowed.

Ventilator bundleVentilator hourly/daily charge includes ventilator machine, PEEP, IMV circuit, breathing circuit, technician time, related disposables and manual ventilation during in-hospital transport.

Oxygen bundleOxygen hourly/daily charge includes oxygen delivery supplies and equipment (flow meter, humidifier, delivery devices), oxygen itself, technician time and disposable supplies (nasal cannula, masks, tents, etc.).

Oxygen/ventilator interactionAn oxygen hourly/daily charge is not reimbursed separately from a ventilator hourly/daily charge.

Billing, Claim Adjustment, and Provider Directions

Billing Rule

Claim adjustment and benefit determination — adjust claims to remove unbundled/duplicative charges; base determinations on member benefit contract and unbundling rules.

Adjust claims to remove charges that have been unbundled or are duplicative. Benefit determinations are based on the member's benefit contract and the unbundling rules described below. Providers must code and document services according to industry coding guidelines and Blue Cross Blue Shield - South Carolina policies. Claims containing charges considered non‑reimbursable or not separately billable will be adjusted to remove those charges.

Claims will be adjusted to remove unbundled or duplicative charges.
Benefit determinations are governed by the member's benefit contract language.

Billing Rule

Blood billing rule — Blood Charge includes products, administration, processing, supplies and personnel; do not bill separately.

The Blood Charge includes the blood product(s) and all related services and fees. Do not bill these items separately from the Blood Charge.

Charge Group Definitions

inv-15: Non‑Reimbursable/Unbundled Charges

DefinitionBilled charges for hospital services, supplies, equipment and/or items that the Plan will not reimburse because they are unbundled, fragmented or duplicative and should reasonably be included in another charge billed to the Plan for the same member on the same day.

ScopeIncludes facility administrative costs, routine and reusable equipment, and routine disposable supplies when billed separately from an inpatient room, specialty unit or other overall facility charge.

ConsequenceCharges meeting this definition are not reimbursable if billed separately and apart from the applicable overall facility or departmental charge.

inv-16: Recovery Room Charge

DefinitionRecovery Room Charge includes all nursing care, personnel, and routine disposable and/or reusable equipment, supplies and items appropriate for the recovery room setting.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyInpatient Non-Reimbursable Charge/Unbundling Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOctober 1, 2018

Next Review DateN/A

SourceLink

On This Page

Exception - Laboratory: A venipuncture performed by laboratory personnel (not nursing staff) is reimbursable as a covered service.

Radiology charge includes: all nursing care, personnel, routine/scout and routine films, stat and call back charges and related fees required to complete the radiology procedure.

Exception - Radiology: IV and oral contrast are allowed to be billed separately from the Radiology charge.

Cardiovascular charge includes: all nursing care, personnel, routine disposable and reusable equipment, and fees necessary to complete cardiovascular procedures (includes EKG, treadmill testing, catheterization, echocardiogram, fetal/adult monitoring); cardiopulmonary resuscitation (CPR) is not separately billable.

Respiratory charge includes: all nursing care, respiratory technician time and personnel, ventilator machine and circuit, PEEP, breathing circuit, disposables, manual ventilation during in-hospital transport, intubation/extubation and related supplies, respiratory assessment, endotracheal tube care, and related fees.

Respiratory rule: oxygen hourly/daily charge is not reimbursable separately from a ventilator hourly/daily charge; when more than one level of respiratory/ventilation support occurs in the same 24-hour period only the highest level of respiratory support will be allowed.

Blood product(s) and all blood derivatives and components are included.
Administration and nursing care related to transfusion are included.
All routine disposable and reusable equipment, supplies, processing, storage, testing and handling fees necessary to obtain or administer blood are included.
Claims for blood-related items billed separately from the Blood Charge will be denied/adjusted.

Billing Rule

Laboratory billing rule — Laboratory Charge includes specimen collection supplies, venipuncture by nursing, stat/callback charges and personnel; venipuncture by lab may be billed separately per policy.

Laboratory charges bundle specimen collection supplies and routine collection-related personnel costs. Do not bill these items separately from the Laboratory Charge except where expressly allowed.

All disposable supplies and collection devices are included in the Laboratory Charge.
Stat and callback charges and associated personnel time are included.
Venipuncture performed by nursing staff is included (bedside glucose testing excluded).
Venipuncture performed by laboratory personnel (not nursing staff) may be billed separately as allowed by policy.

Billing Rule

Radiology billing rule — Radiology Charge includes routine films, scout films, stat/callback charges and personnel; IV and oral contrast are allowed to be billed separately (exception).

Radiology procedure charges include routine imaging elements and associated personnel time and supplies. Do not separately bill items that are part of the Radiology Charge except for allowed contrast charges.

Call back time, stat charges, scout and routine films/photographs are included in the Radiology Charge.
Routine personnel, disposables and supplies are included.
IV and oral contrast are an exception and may be billed separately when appropriate.
Charges fragmented from the Radiology Charge will be adjusted/denied.

Billing Rule

Cardiovascular billing rule — Cardiovascular Charge includes EKG, treadmill, cath, echo and monitoring; CPR is not separately billable.

Cardiovascular procedure charges bundle testing and monitoring services and related personnel and supplies. Do not bill bundled cardiovascular items separately.

EKG, treadmill testing, catheterization, echocardiogram and fetal or adult cardiac monitoring are included in the Cardio Vascular Charge.
Associated nursing care, personnel, disposables and supplies are included.
Cardiopulmonary resuscitation (CPR) is not separately billable and should not be billed apart from the cardiovascular/global service charge.

Billing Rule

Respiratory billing rule — Respiratory Therapy Charge bundles ventilator and oxygen components and related technician time; oxygen charges are not reimbursed separately except as allowed by the 'highest support per 24 hours' rule.

Respiratory therapy and oxygen support charges include equipment, disposables, technician time and related services. Bill only the highest level of respiratory support per 24‑hour period and do not separately bill oxygen when it is bundled with ventilator support.

Respiratory Therapy Charge includes technician time, disposables, supplies, equipment and routine personnel.
Ventilator hourly/daily charge includes the ventilator machine, circuits (IMV/PEEP), related disposables, technician time, manual ventilation during transport, intubation/extubation and related supplies.
Oxygen hourly/daily charge includes oxygen delivery equipment, humidifier, flow meter, delivery devices (nasal cannula, masks, tents, isolette, T‑piece), oxygen supply, disposables and technician time.
Oxygen charges are not reimbursed separately when billed with a ventilator hourly/daily charge.
When multiple levels of respiratory/ventilation support occur within the same 24‑hour period, only the highest level of support will be reimbursed.

Airways, masks, face tents, monitors and accessories, oxygen and oxygen delivery equipment, suction equipment; blankets and warming covers.

Personnel and timeAdditional personnel charges, call back time and all nursing care provided in this setting are included in the Recovery Room Charge.

inv-17: Labor and Delivery Room Charge

DefinitionLabor and Delivery Room Charge includes all nursing care, personnel, and routine disposable and/or reusable equipment, supplies and items appropriate for that setting.

Typical inclusionsBlood pressure cuff, thermometer, monitors, oxygen and oxygen supplies, betadine, 4x4 pads, ink pads, gloves, lubricant, amnihook, cord clamp, drapes, sutures, name bands, foot printer, suction bulbs, instruments, gowns, irrigation solutions, OB pack, Ambu bag and crash cart.

Nursing careAll nursing care provided in this setting, including surgical prep for procedures, is included in the Labor and Delivery Room Charge.

inv-18: Blood Charge

DefinitionBlood Charge includes the blood itself, all blood products, any related nursing care (including administration), personnel, routine disposable and/or reusable equipment and supplies, and fees necessary to obtain, handle, process, store, test and/or administer the blood.

Typical inclusionsBlood and blood products, administration and processing fees, storage and testing fees, related supplies and personnel.

inv-19: Laboratory Charge

DefinitionLaboratory Charge includes all nursing care, personnel, routine disposable and/or reusable equipment, supplies and fees necessary to complete the laboratory procedure.

Typical inclusionsDisposable supplies and collection devices, stat and call back charges, venipuncture performed by nursing staff (excluding bedside glucose), arterial punctures unless performed by respiratory, and personnel associated with specimen collection.

ExceptionVenipuncture performed by laboratory personnel (not nursing staff) is reimbursable separately.

inv-20: Radiology Charge

DefinitionRadiology Charge includes all nursing care, personnel, routine disposable and/or reusable equipment, supplies and fees necessary to complete the radiology procedure.

Typical inclusionsCall back time, stat charges, scout and routine films or photographs, and associated personnel and supplies.

ExceptionIV and oral contrast are allowed to be billed separately from the Radiology Charge.

inv-21: Cardio Vascular Charge

DefinitionCardio Vascular Charge includes all nursing care, personnel, routine disposable and/or reusable equipment, supplies and fees necessary to complete cardiovascular procedures.

Typical inclusionsCharges for EKG, treadmill testing, catheterization, echocardiogram, fetal or adult cardiac monitoring and associated personnel and supplies.

Non-reimbursable serviceCardiopulmonary resuscitation (CPR) is not separately billable.

inv-22: Respiratory Therapy Charge

DefinitionRespiratory Therapy Charge includes all nursing care, respiratory technician time, personnel, routine disposable and/or reusable equipment, supplies and fees necessary to complete respiratory therapy procedures or services.

Typical inclusionsOxygen and breathing treatments (aerosol, IPPB, incentive spirometry, ultrasonic nebulizer), ventilator machine, PEEP, IMV circuit, breathing circuit, technician time, disposables, manual ventilation during transport, intubation/extubation, respiratory assessment and endotracheal tube care.

Billing interactionAn oxygen hourly/daily charge is not reimbursed separately from a ventilator hourly/daily charge; when multiple levels of support occur only the highest level is allowed per 24 hours.