CurrentBlue Cross Blue Shield - WisconsinPolicy G-01017

Preadmission Services for Inpatient Stays

Defines which outpatient services provided before an inpatient admission are included in inpatient reimbursement (payment window) and which are separately reimbursable; applies to providers billing Blue Cross Blue Shield - Wisconsin members per the policy's terms.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyPreadmission Services for Inpatient Stays

Policy CodePolicy G-01017

Change TypeNo material changes

Effective DateSep 11, 2025

Next Review Date

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and follow proper billing and submission guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-dayadmitting hospitals window

1-dayother hospitals/units window

CAH excludedCritical Access Hospitals

Donor post-kidney txoutside payment window example

PD / 51billing indicators

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Preadmission Coverage Criteria

Preadmission coverage criteria

Covered when criteria below are met; specifies which preadmission outpatient services are included in inpatient reimbursement (payment window) versus separately reimbursable.

Preadmission services policy overview (applies unless provider, state, federal, or CMS contracts/requirements indicate otherwise).

For admitting hospitals (including entities wholly owned/operated by or under arrangements with the admitting hospital): preadmission services are included in inpatient reimbursement for the three days prior to and including the day of admission and are not separately reimbursable.

ALL of the following

Psychiatric hospitals and units
Inpatient rehabilitation facilities and units
Long-term care hospitals
Children's hospitals
Cancer hospitals

Critical Access Hospitals (CAH) are excluded from the three-day and one-day payment windows; preadmission services for CAHs are separately reimbursable from the inpatient stay reimbursement.

The three-day and one-day payment windows do not apply to preadmission services that are included in the Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) all‑inclusive rate.

Preadmission services included in the inpatient reimbursement consist of all diagnostic outpatient services and admission‑related outpatient nondiagnostic services; a hospital may attest that specific nondiagnostic services are unrelated by using Condition Code 51, and providers should append modifier PD to services subject to the preadmission payment window.

ANY of the following

Ambulance services
Donor post‑kidney transplant complication services
Maintenance renal dialysis services
Services provided by skilled nursing facilities
Services provided by home health agencies
Services provided by hospices
Unrelated nondiagnostic services (may be attested with Condition Code 51)

Standard correct coding and documentation requirements apply; claims must be supported by documentation and appropriate coding (CPT/HCPCS/revenue codes); noncompliance may result in denials, recoveries, or adjustments.

Billing Codes and Payment Window

Modifiers and condition codes for preadmission billingModifier

PD	Modifier PD - Indicates that the service is related to the inpatient admission
51	Condition Code 51 - Denotes attestation of unrelated outpatient non-diagnostic services

Payment window timeframe

Admitting hospitals payment windowThree days prior to and including the day of admission — preadmission services included in inpatient reimbursement and not separately reimbursable (includes entities wholly owned/operated by or under arrangements with the admitting hospital).

Critical Access Hospitals (CAH)CAHs are excluded from the one- and three-day payment windows; preadmission services are separately reimbursable from the inpatient stay reimbursement.

RHC/FQHC exceptionThe three-day or one-day payment window does not apply to preadmission services included in the RHC or FQHC all-inclusive rate.

Authorization and Documentation Requirements

Prior Authorization

Authorization, medical necessity, and correct billing required

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; follow proper billing and submission guidelines using CPT, HCPCS, and/or revenue codes and ensure billed services are fully supported in the medical record and/or office notes. Failure to follow coding/billing guidelines or reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement.

Obtain and document any required prior authorization and confirm medical necessity before admission-related services are provided.
Bill services using industry-standard CPT, HCPCS, and/or revenue codes and retain medical record documentation that fully supports billed services.
Follow state, federal, and CMS mandates that may supersede this policy.

Key Definitions

Admission Related Outpatient Nondiagnostic Services

DefinitionAdmission Related Outpatient Nondiagnostic Services — Services that are furnished in connection with the principal diagnosis assigned to the inpatient admission.

Context within payment windowThese nondiagnostic outpatient services are considered when determining whether preadmission services are included in inpatient reimbursement under the applicable payment window (three-day or one-day) for the admitting facility type.

Documentation expectationProviders should document the connection to the principal diagnosis to support inclusion or separate reimbursement as applicable.

Condition Code 51

Condition Code 51Denotes attestation of unrelated outpatient non-diagnostic services.

Billing use