CurrentBlue KCPolicy POL-PP-257

Inpatient Only Procedures

Governs payment treatment of procedures on the CMS Inpatient-Only list for Blue KC members and providers; affects all providers and facilities under Blue KC lines of business unless a contract specifies otherwise.

Policy Summary

PayerBlue KC

PolicyInpatient Only Procedures

Policy CodePolicy POL-PP-257

Change TypeAdministrative / Operational

Effective Date9/1/2025

Next Review Date9/1/2026

Key ActionIf an inpatient-only listed procedure is performed and billed as outpatient, no payment will be made to the facility for that procedure or any other services on the same date of service.

SourceLink

POLICY UPDATE CHANGES

Updated link to inpatient only list, addendum E.

Corrected effective date to 9/1/2025 in a prior revision.

2025-09-01policy effective

2026-09-01next review

004version

Facility, Ambulatoryapplies to

Coverage Criteria

Policy Summary

PayerBlue KC

PolicyInpatient Only Procedures

Policy CodePolicy POL-PP-257

Change TypeAdministrative / Operational

Effective Date9/1/2025

Next Review Date9/1/2026

Key ActionIf an inpatient-only listed procedure is performed and billed as outpatient, no payment will be made to the facility for that procedure or any other services on the same date of service.

SourceLink

On This Page

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.

Primary coverage criteria

Covered when ALL of the following are met:

ALL of the following

ONE of
- Procedure is listed on the CMS Inpatient-only list effective 9/1/2025 (Blue KC will follow the CMS Inpatient-only list).
  Reference CMS Addendum E for the inpatient-only procedure code list.
- Procedure is performed and billed as an inpatient procedure in an acute hospital setting.
The surgical service customarily requires inpatient care because of at least one of the following: 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.
Provider or facility does not have a Blue KC network participation agreement that specifies a different inpatient reimbursement rate for the inpatient-only code.

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

This is a billing consequence when coverage criteria are not met (outpatient billing for inpatient-only procedures).

Coding and Code Sources

Inpatient-only procedure codes (CMS Addendum E)mixed

See CMS 2025 NFRM OPPs Addenda (Addendum E)

Inpatient-only procedure code list (refer to CMS zip file)

Source of inpatient-only list

Source documentCMS 2025 NFRM OPPs Addenda (Addendum E) — available from the CMS zip file (2025-nfrm-opps-addenda.zip)

Access URLhttps://www.cms.gov/license/ama?file=/files/zip/2025-nfrm-opps-addenda.zip

Effective alignment dateBlue KC aligns to Addendum E effective 9/1/2025

Provider Actions & Billing Rules

Billing Rule

Outpatient billing for inpatient-only procedures

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

Applies to all providers and facilities unless a provider's Blue KC network participation agreement specifies a reimbursement rate for the inpatient-only code.

Documentation Required

Reference to CMS Inpatient-Only list (Addendum E)

Blue KC follows the CMS Inpatient-only list effective 9/1/2025; providers should reference CMS Addendum E in the 2025 NFRM OPPs addenda for the inpatient-only procedure code list.

CMS 2025 NFRM OPPs Addenda (Addendum E) available at: https://www.cms.gov/license/ama?file=/files/zip/2025-nfrm-opps-addenda.zip

Definitions

Inpatient-only list

Definition of inpatient-only listProcedures Blue KC will only pay as inpatient when performed in an acute hospital setting

Rationale — invasivenessIncludes surgical services that customarily require inpatient care due to the invasive nature of the procedure

Rationale — patient conditionIncludes services required because of the typical underlying physical condition of patients who need the service

Rationale — postoperative monitoringIncludes services that require at least 24 hours of postoperative recovery time or monitoring before safe discharge

Rationale for inpatient designation

Primary rationaleSurgical services that customarily require inpatient care due to invasiveness, patient condition, or need for at least 24 hours postoperative monitoring

Invasiveness criterionProcedures of an invasive nature that typically necessitate inpatient admission

Patient condition criterionProcedures for patients whose underlying physical condition typically requires inpatient care

Recovery/monitoring criterionProcedures requiring ≥24 hours postoperative recovery or monitoring before safe discharge