CurrentHealth NetPolicy CC.PP.500

3-Day Payment Window

Defines Health Net's reimbursement rules requiring bundling of outpatient diagnostic and related non-diagnostic services furnished within 3 calendar days (or 1 day for non-IPPS hospitals) prior to and including an inpatient admission into the inpatient claim; applies to participating and certain non‑participating hospitals and related entities.

Policy Summary

PayerHealth Net

Policy3-Day Payment Window

Policy CodePolicy CC.PP.500

Change TypeAnnual review / template conversion

Effective Date07/01/2014

Next Review Date

Key ActionWhen outpatient non-diagnostic services during the payment window are unrelated to the admission, include Condition Code 51 on the outpatient facility claim; related entities must append Modifier PD to professional lines when admission occurs within the window.

SourceLink

POLICY UPDATE CHANGES

Conducted annual review, updated policy dates.

Conducted annual review, updated policy dates and code descriptions, removed broken weblinks.

Review and revise policy, deleted 'X' revenue codes as they were no longer valid.

Converted to Corporate Template and Annually reviewed.

3 daysbundling window for IPPS hospitals

1 daybundling window for non‑IPPS hospitals

Condition Code 51attestation code

Modifier PDprofessional modifier

Ambulance & dialysis

08listed annual reviews

Services Subject to Bundling and Precedence Rules

Bundling criteria

Services subject to bundling into the inpatient claim when furnished within the payment window:

IPPS hospitals: Outpatient diagnostic services (including clinical diagnostic laboratory tests) and related non-diagnostic services furnished on the date of admission or within 3 calendar days prior to the date of inpatient admission must be bundled into the inpatient claim (3-day payment window).

Non-IPPS hospitals: Outpatient diagnostic services and related non-diagnostic services furnished on the date of admission or within 1 calendar day prior to the date of inpatient admission must be bundled into the inpatient claim (1-day payment window).

Scope of services subject to bundling: Technical component of outpatient diagnostic services and related non-diagnostic services that are furnished by the hospital and meet the timing criteria above (examples include diagnostic imaging, nuclear medicine, clinical diagnostic laboratory tests, and similar services).

Exclusions: Services specifically excluded from this bundling requirement include ambulance services, maintenance renal dialysis services, and services furnished by skilled nursing facilities, home health agencies, and hospices.

Billing requirement: Outpatient diagnostic services deemed inpatient services under this policy must be bundled on the admitting hospital's inpatient claim; outpatient facility lines with a line-item date of service within the payment window are subject to denial if billed separately.

Attestation and modifier requirements: When outpatient non-diagnostic services during the payment window are unrelated to the admission, the hospital must include Condition Code 51 on the outpatient facility claim; related facilities/related entities must append modifier PD to diagnostic and related non-diagnostic professional service claim lines when an inpatient admission occurs within the payment window (omission of PD is regarded as an attestation that the services are not subject to the window).

Coverage guidance and precedence

Guidance and precedence rules for coverage and payment determinations under this policy.

Policy scope and purpose: This payment policy provides guidance to assist in making coverage and payment determinations and administering benefits; it does not constitute a contract or guarantee of payment and does not dictate medical care.

Hierarchy and applicability: Coverage and payment determinations under this policy are subject to the terms, conditions, exclusions and limitations of the member's coverage documents and to applicable state and federal requirements and plan-level administrative policies; Health Plan retains discretion to change or withdraw the policy.

Regulatory precedence: For Medicaid members, state Medicaid coverage provisions take precedence over this payment policy when conflicts exist; for Medicare members, applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) should be reviewed prior to applying this policy.

Operational notes

Effective date and legal requirements: The posting date may not equal the effective date; applicable legal and regulatory provider-notification requirements govern in case of discrepancy.

Codes, Revenue and Date-of-Service Thresholds

Examples of outpatient diagnostic revenue/CPT codes subject to bundlingmixedCovered

0254	Drugs incident to other diagnostic services
0341	Nuclear medicine, diagnostic
0482	Cardiology, Stress Test
G0278	Cardiology diagnostic

(Additional listed diagnostic codes present in source)mixedCovered

0255	Drugs incident to radiology
0343	Nuclear medicine, diagnostic radiopharmaceuticals
0371	Anesthesia incident to Radiology
0372	Anesthesia incident to other diagnostic services
0471	Audiology diagnostic
0481	Cardiology, Cardiac Catheter Lab/Other Cardiology
0489	Cardiology, Cardiac Catheter Lab/Other Cardiology
0483	Cardiology, Echocardiology
0918	Testing- Behavioral Health
0919	Testing- Behavioral Health

Cardiology CPT referencesCPTCovered

93451-93464	Cardiac catheterization CPT codes referenced in source
93503	Cardiac catheterization CPT code referenced in source
93505	Cardiac catheterization CPT code referenced in source
93530-93533	Cardiac catheterization CPT codes referenced in source
93561-93568	Cardiac catheterization CPT codes referenced in source
93571-93572	Cardiac catheterization CPT codes referenced in source

Removed revenue codes notemixed

No codes listed

Line-item date of service threshold — LIDOS rules

LIDOS denial window (IPPS)Diagnostic outpatient lines will be denied when the line-item date of service (LIDOS) falls on the day of admission or any of the 3 days immediately prior to the admission; such services must be bundled into the inpatient claim.

LIDOS denial window (Non‑IPPS)For non‑IPPS admitting hospitals, the denial window is the day of admission and the 1 day immediately prior; those outpatient diagnostic lines with LIDOS in that window must be bundled.

Related non‑diagnostic servicesNon‑diagnostic services (other than ambulance and maintenance renal dialysis) provided on the day of admission or within the payment window that are related to the admission are considered inpatient and must be bundled on the admitting hospital's inpatient claim.

Conversion requirementWhen bundled, the admitting hospital must convert CPT codes to ICD-9-CM procedure codes and include only services within the applicable payment window.

Billing Attestations, Modifiers, and Policy Limitations

Billing Rule

Include Condition Code 51 on outpatient facility claims for unrelated non‑diagnostic services

When outpatient non-diagnostic services during the payment window are unrelated to the admission, the hospital must bill those services separately and include Condition Code 51 (Attestation of Unrelated Outpatient Non-diagnostic Services) on the outpatient facility (UB-04) claim; outpatient facility claims for such services will be denied if Condition Code 51 is not included and the line-item date of service (LIDOS) falls on the day of admission or within the 3 days (or 1 day for non‑IPPS hospitals) immediately prior to admission.

Maintain documentation in the member's medical record to support that the outpatient non-diagnostic services are unrelated to the inpatient admission.
Include Condition Code 51 on separately billed outpatient non-diagnostic services furnished within the payment window.

Billing Rule

Append modifier PD on related-entity professional claims when admission is confirmed

Key Terms and Billing Codes

Admitting Hospital

DefinitionAdmitting Hospital - the hospital at which inpatient admission occurs

Scope noteIncludes the hospital that records the inpatient admission and is responsible for the inpatient claim submission.

Relationship to related facilitiesAdmitting Hospital may have entities wholly owned, wholly operated, or under arrangement that furnish services subject to this policy.

Non-IPPS Hospital

DefinitionNon-IPPS Hospital - an admitting hospital that is not paid under the Medicare hospital Inpatient Prospective Payment System

Payment-window implicationFor non‑IPPS hospitals, the bundling/payment-window is 1 day prior to admission (instead of 3 days).

Policy Updates and Review History

2025-07-17annual_reviewLatest

Conducted annual review and updated policy dates.

2024-11-15annual_review

Conducted annual review and updated policy dates.

2023-08-29annual_review

Conducted annual review and updated policy dates.

Policy Summary

PayerHealth Net

Policy3-Day Payment Window

Policy CodePolicy CC.PP.500

Change TypeAnnual review / template conversion

Effective Date07/01/2014

Next Review Date

SourceLink

On This Page

Provider responsibilities: Providers are expected to exercise professional medical judgment; this policy is not medical advice and providers remain responsible for treatment decisions.

Once the related entity receives confirmation of the member's inpatient admission, the related entity must append modifier PD to all claim lines for diagnostic services and for non-diagnostic services identified as related to the inpatient stay that were furnished on the date of admission or within the 3 days (or 1 day for non‑IPPS hospitals) prior to admission; omission of PD is treated as an attestation that the services are not subject to the payment window.

Related entity (physician practice/office) must manage billing processes to ensure PD is appended when an inpatient admission has occurred.
Physician non-diagnostic services that are unrelated to the admission should be billed without the PD modifier.

Note

Policy provides guidance but does not guarantee payment

This payment policy is intended to guide payment determinations and administration of benefits but does not constitute a contract or guarantee of payment; coverage and payment remain subject to the terms, conditions, exclusions and limitations of the member's coverage documents and applicable state and federal requirements.

Health Plan may change, amend or withdraw this payment policy; legal and regulatory requirements govern if discrepant with the policy effective date.
This policy does not constitute medical advice or dictate medical practice.

Documentation Required

Follow Medicaid and Medicare rules where applicable

State Medicaid coverage provisions take precedence over this payment policy for Medicaid members; for Medicare members, reviewers must consult applicable Medicare NCDs and LCDs before applying this policy.

Refer to the state Medicaid manual for any conflicting coverage provisions.
Refer to the CMS website for applicable NCDs and LCDs prior to applying this policy.

Policy applicationNon‑IPPS hospitals are still subject to bundling for services within the 1-day window except for specifically excluded services (e.g., ambulance, maintenance renal dialysis).

Related Facility

DefinitionRelated Facility - an entity that is 'wholly owned' or 'wholly operated' by the admitting hospital, or an entity under arrangement with the admitting hospital.

Wholly operated meaningWholly Operated: the hospital has exclusive responsibility for conducting and overseeing the entity's routine operations (see 42 CFR §412.2).

Wholly owned meaningWholly Owned: the hospital is the sole owner of the entity (see 42 CFR §412.2).

Condition Code 51

Definition and useCondition Code 51 - Attestation of Unrelated Outpatient Non-diagnostic Services; used on outpatient facility (UB-04) claims when preadmission non-diagnostic services are clinically distinct and unrelated to the inpatient admission.

When requiredHospitals must include Condition Code 51 on the outpatient facility claim when attesting that specific preadmission non-diagnostic services are unrelated to the inpatient stay.

EffectWhen properly attested with Condition Code 51, specific non-diagnostic services may be billed separately rather than bundled into the inpatient claim.

Modifier PD

DefinitionModifier PD - Diagnostic or related non-diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days; used on outpatient professional claim lines subject to the 3-day window.

Related-entity billing useRelated entities must append modifier PD to diagnostic and related non-diagnostic professional services furnished within the payment window when they have confirmation of the inpatient admission.

Omission implicationFailure to append Modifier PD is regarded as an attestation that the services are not subject to the payment window (i.e., not related to the admission).

Health Plan

Definition'Health Plan' means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any affiliate.

ApplicabilityThe term applies to plans that have formally adopted this payment policy and are operated or administered by Centene Management Company, LLC or its affiliates.

Policy relationshipAdopted Health Plans must follow the payment and billing guidance in this policy subject to member coverage documents and applicable state/federal requirements.

2022-09-01annual_review

Conducted annual review; updated policy dates and code descriptions, and removed broken weblinks.

2021-09-01annual_review

Conducted review; updated policy dates and removed product type.

2020-09-01annual_review

Conducted review and updated policy documentation.

2019-09-01review

Conducted review of the policy.

2018-03-01revision

Reviewed and revised policy; deleted 'X' revenue codes that were no longer valid.

2017-01-19template_conversion

Converted to Corporate Template and conducted annual review.

2016-07-11template_conversion

Converted to new template.

2014-07-01effective_date

Original effective date of the policy.