CurrentBlue Cross Blue Shield - TexasPolicy CPCP002

Inpatient/Outpatient Unbundling Policy- Facility

This policy governs facility-level reimbursement and coding rules for unbundled, incidental, routine, and bundled supplies/services for inpatient and outpatient settings for Blue Cross and Blue Shield of Texas members and participating providers.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyInpatient/Outpatient Unbundling Policy- Facility

Policy CodePolicy CPCP002

Change TypeNo material change

Effective DateMar 6, 2024

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional records upon request for claim review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5.0policy version

Mar 6, 2024plan effective

Dec 21, 2023approval

Not reimbursedoxygen charges

0274-0276,0278implant rev codes

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.

Facility Unbundling and Bundled Charge Criteria

Charges that are included in another facility charge or are routine/incidental are not eligible for separate reimbursement.

ALL of the following

Includes items prepared or opened but not used or implanted, non-utilized supplies or DME (e.g., crash carts, emergency drugs), items opened by mistake, change of mind by the surgeon, equipment failure/technical difficulties, surgery cancellation, and large packages when more appropriate packaging exists.

ALL of the following

Examples include syringes, needles, blood or urine testing supplies (except as used in diabetes treatment), sheaths, bags, elastic garments, stockings, bandages, gauze, and replacement batteries.

Incidental services that are clinically integral to the primary procedure (including technical charges for equipment purchase, rental, and maintenance) may not be billed separately by any provider or entity.

ALL of the following

Examples include floor stock items such as drapes, saline solutions (flush and irrigation), reusable items, regular room, dietary services, nursing services, minor medical and surgical supplies, and equipment normally provided to all members (e.g., pulse oximeter, blood pressure cuffs, bedside table).

ALL of the following

Examples (not all-inclusive): needles, alcohol swabs, arterial blood gas kits, baby powder, band-aids, basins, bedpans, blood tubes, cotton balls, drapes, emesis basins, gloves, gowns, heat lights, ice packs, irrigation solutions, pillows, linens, soap, and similar items provided in the setting.

Surgical room and service charges include nursing personnel services, supplies, and equipment; listed surgical room equipment/services should not be billed separately.

ALL of the following

Respiratory therapy charges include nursing care, respiratory technician time, personnel, routine disposable/reusable equipment and supplies, and oxygen/breathing treatments such as aerosol, incentive spirometry, IPPB, percussion/postural drainage, and ultrasonic nebulizer.
Ventilator charges include respiratory assessment, intubation/extubation and related supplies, manual ventilation during in-hospital transport, endotracheal tube care, Ambu bag, ventilator machines, breathing circuits, IMV circuit, PEEP, technician time, water, and disposable ventilator supplies.

Claims are subject to code edit protocols and claim review; providers should submit accurate documentation and may be asked to provide additional documentation upon request.

Oxygen charges

Coverage stance for oxygen-related facility charges:

ALL of the following

Oxygen charges include, but are not limited to, oxygen, water, respiratory therapy technician time, distribution/delivery equipment (e.g., flow meter, humidifier, croupette), all disposable supplies, nasal cannula, nasal catheter, associated masks, tent or hood, T-piece, and isolette(s).
Oxygen-related consumables and routine equipment that are ordinarily provided as part of respiratory therapy or facility routine supplies are considered bundled and ineligible for separate payment.

ref_admin_note_or_empty_string_if_none_that_should_not_be_displayed_elsewhere_called_note": ""

ref": "b0_1

title": "Oxygen charges"

Ventilator and implant charges

Coverage and documentation expectations for ventilator and implant-related charges:

ALL of the following

Ventilator components and services include respiratory assessment, intubation/extubation charges and related supplies, manual ventilation during in-hospital transport, endotracheal tube care, Ambu bag, ventilator machines, breathing circuits, IMV circuit, PEEP, technician time, water, and disposable ventilator supplies.
Respiratory therapy charges more broadly include nursing care, respiratory technician time, routine disposable and/or reusable equipment, and specified oxygen/breathing treatments, which are part of the bundled respiratory therapy charge.

For implant-related revenue codes 0274, 0275, 0276, and 0278, providers must submit vendor invoices that clearly indicate the units used corresponding to the billed units; if units do not match or are not noted, the revenue code lines will be denied unless otherwise agreed.

Revenue code 0278 should not be billed for items that may be considered supplies; such charges may be ineligible for separate reimbursement and treated as unbundled under this policy.

Provider Responsibilities and Billing Actions

Documentation Required

Submit accurate documentation and respond to claim review requests

Providers are responsible for submission of accurate documentation of services performed and must code claims using valid HIPAA-approved code sets and industry standard coding guidelines. Claims are subject to code edit protocols and claim review (including plan terms, provider contract language, medical policies, and coding policies); upon request, providers are urged to submit any additional documentation.

Use valid code combinations from HIPAA-approved code sets (CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, etc.).
Claims may be reviewed against benefit coverage, provider contract language, medical and coding policies; respond with requested documentation promptly.

Billing Rule

Provide vendor invoices with matching units for implant revenue codes 0274–0276, 0278

For revenue codes 0274, 0275, 0276, and 0278, submit a vendor invoice that clearly indicates the units used that correspond to the billed charges; units on the invoice must match the units billed or the revenue line(s) will be denied unless otherwise agreed.

Vendor invoice must support supplies used and clearly indicate units.
If supplies were purchased in bulk, the invoice must note the units that apply to the claim.
0278 should not be billed for items that are considered supplies; such charges may be ineligible for separate reimbursement.

Denial Risk

Do not bill oxygen charges separately — not eligible for reimbursement

Do not bill oxygen charges separately; oxygen charges (including oxygen, water, respiratory technician time, distribution/delivery equipment, and all disposable supplies such as nasal cannula, masks, tents, T-piece, and isolette) are not eligible for separate reimbursement.

Oxygen distribution or delivery equipment examples: flow meter, humidifier, croupette.
Disposable supplies and respiratory therapy time related to oxygen are included and should not be billed separately.

Definitions and Scope Terms

Unbundling

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

ScopeApplies to medical and surgical services, supplies, and equipment; not all-inclusive

IntentNot intended to affect clinical decisions; providers should use independent medical judgment

Mutually Exclusive

DefinitionProcedures that cannot reasonably be performed together or 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 co-performance.

Review basisDeterminations are made using code definitions and anatomic considerations

Point-of-Care Testing (POC/POCT)

SettingOccurs at point-of-care rather than in a centralized laboratory

Clinical impactResults can immediately influence treatment decisions

Ventilator charges

Included technician servicesRespiratory assessment, intubation and/or extubation charges, manual ventilation during in-hospital transport, and endotracheal tube care

Included equipment/componentsAmbu bag, ventilator machine(s), breathing circuit, IMV circuit, PEEP

Other inclusionsTechnician time, water, and disposable ventilator supplies

Oxygen charges

Coverage stanceOxygen charges are not eligible for separate reimbursement

Included componentsOxygen, water, respiratory therapy technician time

Delivery equipmentOxygen distribution/delivery supplies or equipment (e.g., flow meter, humidifier, croupette)

Disposable suppliesAll disposable supplies including nasal cannula, nasal catheter, associated masks, tent/hood, T-piece, isolette(s)

OpenPayer

Inpatient/Outpatient Unbundling Policy- Facility

Facility Unbundling and Reimbursement Criteria

Coding Standards and Revenue/Code Use

Provider Responsibilities and Billing Actions

Definitions and Scope Terms