CurrentBlue KCPolicy POL-PP-257

Inpatient Only Procedures

Governs payment for surgical procedures designated on the CMS inpatient-only list and affects all providers and facilities billing Blue KC lines of business; outpatient reporting of an inpatient-only procedure will not be paid.

Policy Summary

PayerBlue KC

PolicyInpatient Only Procedures

Policy CodePolicy POL-PP-257

Change TypeAdoption of CMS list; effective date corrected

Effective Date9/1/2025

Next Review Date9/1/2026

Key ActionBill inpatient for procedures on the CMS inpatient-only list; outpatient claims for those procedures will not be paid.

SourceLink

POLICY UPDATE CHANGES

Effective 9/1/2025, Blue KC will follow the CMS Inpatient-only list.

Corrected effective date to 9/1/2025.

Updated link to inpatient only list, addendum E.

POL-PP-257policy identifier

9/1/2025effective

9/1/2026next review

Addendum Ecoding source

Coverage Criteria

Inpatient-only coverage rules

Covered when the following rules are met:

Procedures listed on the CMS Inpatient-only list are payable only when billed as inpatient in an acute hospital setting.

Blue KC will follow the CMS Inpatient-only list effective 9/1/2025; these procedures customarily require inpatient care due to the invasive nature of the procedure, the typical underlying physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery or monitoring before safe discharge.

If a surgery/procedure on the inpatient-only list is performed as outpatient and reported on an outpatient claim, no payment will be made to the facility for the surgery/procedure or for any other services provided on the same date of service.

This policy applies to all providers and facilities unless the provider's Blue KC network participation agreement contains a specific rate of reimbursement for the inpatient-only code.

Policy Summary

PayerBlue KC

PolicyInpatient Only Procedures

Policy CodePolicy POL-PP-257

Change TypeAdoption of CMS list; effective date corrected

Effective Date9/1/2025

Next Review Date9/1/2026

Key ActionBill inpatient for procedures on the CMS inpatient-only list; outpatient claims for those procedures will not be paid.

SourceLink

On This Page

Provider Actions and Billing Rules

Denial Risk

Payment denial for outpatient reporting of inpatient-only procedures

If a surgery or procedure on the inpatient-only list is performed and reported on an outpatient claim, Blue KC will make no payment to the facility for that surgery/procedure or for any other services provided on the same date of service.

Applies when an inpatient-only procedure is performed as outpatient and submitted on an outpatient claim.
No payment will be made to the facility for the inpatient-only procedure or any other services on that date of service.

Prior Authorization

Requirement to bill as inpatient

Effective 9/1/2025, Blue KC will follow the CMS Inpatient-only list; procedures on that list will only be paid when billed as inpatient in an acute hospital setting.

The inpatient-only list includes surgeries/procedures that customarily require inpatient care due to invasiveness, patient condition, or the need for at least 24 hours postoperative recovery/monitoring.
This policy applies to all providers and facilities unless a provider's Blue KC network participation agreement specifies a different reimbursement rate for the inpatient-only code.

OpenPayer

Inpatient Only Procedures

Coverage Criteria

Coding and Code List

Provider Actions and Billing Rules

Definitions