CurrentPremera BluecrossPolicy N/A

Preadmission testing (3-calendar day/72-hour rule)

Governs billing and reimbursement for diagnostic and non-diagnostic services performed on the day of inpatient admission or within the prior three calendar days (including the 72-hour period) for Premera Blue Cross lines of business; applies to hospitals and providers submitting facility (UB-04/837I) claims.

Policy Summary

PayerPremera Bluecross

PolicyPreadmission testing (3-calendar day/72-hour rule)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2018

Next Review DateN/A

Key ActionBill related diagnostic and non-diagnostic services occurring on the admission date or within three calendar days (including the 72-hour period) on the same inpatient claim; do not bill them separately on an outpatient facility claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-calendar daywindow that groups preadmission services into inpatient claim

UB-04/837Iclaim forms to which policy applies

Multiple reviewspolicy review history through 06/12/25

Multipleexcluded service categories

Preadmission Testing Coverage Rules

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Preadmission testing coverage rules

Covered when the following billing rules and exceptions are met:

ALL of the following

All related diagnostic and non-diagnostic services performed on the date of an inpatient admission or within three calendar days (including the 72-hour period) are considered part of the inpatient admission and are not separately billable or reimbursable when billed on a separate outpatient facility claim.

ALL of the following

Related services rendered within the three-calendar day window or immediate 72-hour period prior to admission must be billed on the same claim as the inpatient admission.

ALL of the following

Services within the three-calendar day/72-hour window that are unrelated to a planned inpatient admission should be billed on a separate outpatient facility claim and must be identified using Condition Code 51 (Attestation of Unrelated Outpatient Non-Diagnostic Services) in UB-04 Field Locator 18-28.

ALL of the following

Services rendered on the date of an unplanned inpatient admission originating from the emergency room should be included on the inpatient claim.
Such unplanned emergency inpatient admissions should be identified using Admission Type Code 1 - Emergency in UB-04 Field Locator 14.
Emergency room visits within three calendar days or the immediate 72 hours prior to an inpatient admission that are diagnostically related to the admission will be considered part of the inpatient admission and denied separate reimbursement when billed on a separate outpatient facility claim.

Explicit exclusions (one or more may apply)

Ambulance services are excluded from the three-calendar day/72-hour bundling if not part of a diagnostic service, ER visit, or related to a procedure resulting in inpatient admission.
Maintenance renal dialysis is excluded from the three-calendar day/72-hour bundling if not part of a diagnostic service, ER visit, or related to a procedure resulting in inpatient admission.
Chemotherapy (including chemotherapy administration) is excluded from the three-calendar day/72-hour bundling if not part of a diagnostic service, ER visit, or related to a procedure resulting in inpatient admission.
Outpatient surgery is excluded from the three-calendar day/72-hour bundling if not part of a diagnostic service, ER visit, or related to a procedure resulting in inpatient admission.
Radiation therapy is excluded from the three-calendar day/72-hour bundling if not part of a diagnostic service, ER visit, or related to a procedure resulting in inpatient admission.

ALL of the following

This policy applies to facility services billed on UB-04/CMS-1450 or 837I electronic claim forms.

Exclusion Revenue Codes

Exclusion revenue codes - AmbulanceRevenue | mixed

0540-0549

Ambulance services revenue codes (0540 General; 0541 Supplies; 0542 Medical Transport; 0543 Heart Mobile; 0544 Oxygen; 0545 Air Ambulance; 0546 Neonatal Ambulance Services; 0547 Pharmacy; 0548 EKG Transmission; 0549 Other Ambulance)

Exclusion revenue codes - Radiology / Chemotherapy AdministrationRevenue | mixed

0330-0339

Radiology - Therapeutic and/or Chemotherapy Administration revenue codes (0330 General; 0331 Chemotherapy Administration-Injected; 0332 Chemotherapy Administration-Oral; 0333 Radiation Therapy-Therapeutic and/or Chemotherapy; 0335 Administration-Radiation Therapy; 0339 Chemotherapy Administration-IV/Other)

Exclusion revenue codes - Blood and Blood Components/ProductsRevenue | mixed

0380-0399

Blood and blood components/products and related administration/processing/storage revenue codes (0380 General; 0381 Packed Red Cells; 0382 Whole Blood and Blood Products; 0383 Plasma; 0384 Platelets; 0385 Leukocytes; 0386 Other Blood Components; 0387 Other Derivatives (Cryoprecipitates); 0389 Other Blood/Blood Components; 0390 Administration/Processing/Storage General; 0391 Administration (e.g., transfusions); 0392 Processing and Storage; 0399 Other Blood Handling/Processing and Storage)

Exclusion revenue codes - RX/PharmacyRevenue | mixed

0250-0259, 0631-0637

Pharmacy/RX revenue codes (0250 General; 0251 Generic Drugs; 0252 Non-generic Drugs; 0253 Take-Home Drugs; 0254 Drugs Incident to other diagnostic services; 0255 Drugs incident to radiology; 0256 Experimental Drugs; 0257 Nonprescription; 0258 IV Solutions; 0259 Other Pharmacy; pharmacy extension codes; 0631 Single Source Drug; 0632 Multiple Source Drug; 0633 Restrictive Prescription; 0634 EPO <10K units; 0635 EPO >=10K units; 0636 Drugs requiring detailed coding; 0637 Self-administered drugs)

Exclusion revenue codes - Physical/Occupational/Speech TherapyRevenue | mixed

0420-0449

Physical, Occupational and Speech Therapy revenue codes (0420-0429 Physical Therapy; 0430-0439 Occupational Therapy; 0440-0449 Speech Therapy-Language Pathology; includes visit, hourly, group, evaluation/reevaluation and other therapy codes)

Exclusion revenue codes - DialysisRevenue | mixed

0820-0859, 0880-0889

Dialysis-related revenue codes (0820-0829 Hemodialysis outpatient/home including home supplies/equipment/maintenance/support; 0830-0839 Peritoneal Dialysis outpatient/home; 0840-0849 CAPD outpatient/home; 0850-0859 CCPD outpatient/home; 0880-0889 Miscellaneous Dialysis including ultrafiltration, home dialysis aid visit, other)

Billing and Submission Requirements

Billing Rule

Claim submission requirement for related preadmission services

These related services that are rendered within the three-calendar day window or the immediate 72-hour period prior to admission must be billed on the same claim as the inpatient admission.

Documentation Required

Attesting unrelated outpatient services

Any services that are rendered within the three-calendar day window or the immediate 72-hour period prior to admission that are unrelated to a planned inpatient admission should be billed on a separate outpatient facility claim. Such services must be identified by using Condition Code 51 - Attestation of Unrelated Outpatient Non-Diagnostic Services in Field Locator 18-28 of the UB-04 claim form.

Use Condition Code 51 in UB-04 FL 18-28 to attest services are unrelated to the planned inpatient admission.

Denial Risk

Unplanned ER admissions billing

Any services rendered on the date of an unplanned inpatient admission that are part of an emergency room visit leading to that unplanned admission should be included on the inpatient admission claim. Identify an unplanned emergency inpatient admission using Admission Type Code 1 - Emergency in Field Locator 14 of the UB-04 claim form. Emergency room visits that occur within three calendar days or the immediate 72 hours prior to an inpatient admission and are diagnostically related to the inpatient admission will be considered part of the inpatient admission and will be denied separate reimbursement if billed on a separate outpatient facility claim.

Include ER services that lead to an unplanned inpatient admission on the inpatient claim.
Use Admission Type Code 1 (Emergency) in UB-04 FL 14 to identify the admission.
Do not bill diagnostically related ER services separately within the 3-day/72-hour window — they will be denied separate reimbursement.

Key Definitions

3-Calendar Day Payment Window / 72-Hour Rule

DefinitionThe 3-Calendar Day Payment Window/72-Hour Rule is the period consisting of the day of admission plus the three calendar days preceding the inpatient admission, and includes the 72-hour period immediately before admission (may be longer than 72 hours).

ScopeApplies to services performed on the day of admission and within the three calendar days prior to admission (including the immediate 72-hour period).

Implication for billingRelated services within this window are considered part of the inpatient admission and are not separately billable when submitted on a separate outpatient facility claim.

Preadmission Testing

Billing consequenceSuch related preadmission testing is considered part of the inpatient admission and is not separately reimbursable when billed on a separate outpatient facility claim.

Diagnostic Services

DefinitionDiagnostic Services are examinations or procedures performed in a hospital outpatient setting to obtain information to aid in assessment of a medical condition or identification of disease.

ExamplesExamples include blood chemistry, diagnostic x-rays, isotope studies, electrocardiograms (EKGs), pulmonary function tests (PFTs), and thyroid function tests.

PurposeUsed to determine the nature and severity of an ailment or injury and may be considered preadmission testing when related to an inpatient admission within the 3-day/72-hour window.

Non-Diagnostic Services

Relation to admissionCounted as related preadmission testing when they are associated with the reason for admission and therefore considered part of the inpatient claim.

Billing consequenceNon-diagnostic services related to the admission are not separately billable or reimbursable when billed on a separate outpatient facility claim within the 3-day/72-hour window.