CurrentPremera BluecrossPolicy cmi_171642

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

Governs billing and reimbursement for diagnostic and non-diagnostic services related to an inpatient admission performed on the day of admission or within the prior three calendar days (including the 72-hour window); applies to providers and facilities across Premera Blue Cross lines of business and related affiliates.

Policy Summary

PayerPremera Bluecross

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

Policy CodePolicy cmi_171642

Change TypeClarifications and additions (non-material)

Effective Date

Next Review Date

Key ActionRelated services within the three-calendar day/72-hour window must be billed on the same claim as the inpatient admission.

SourceLink

POLICY UPDATE CHANGES

Added an exception to exclude Psychiatric Hospitals and units, Inpatient Rehabilitation Hospitals and units, Long-Term Care Hospitals, Children's Hospitals, Mother/Baby claims and Cancer Hospitals from the policy requirements.

Clarified Purpose statement and added reference to the 72-hour rule relative to the 3-calendar day payment window.

Added clarification that the 'related services' that would not be separately reimbursed are those services billed on an Outpatient facility claim.

3-calendar day / 72-hourpayment window prior to admission considered part of inpatient claim

6 code groupsRevenue codes excluded

Annual thru 2025-06-12policy review history

Exempt hospital types listed

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.

facility types exempt

Preadmission Testing Coverage Criteria

Preadmission testing coverage criteria

Covered when ALL of the following are met:

Related diagnostic and non-diagnostic services performed by an admitting hospital on the date of an inpatient admission or within the prior three calendar days (including the 72-hour period immediately preceding admission) are considered part of the inpatient admission hospital claim and are not separately billable when billed on a separate outpatient facility claim.

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.

Unrelated outpatient services (bill separately): 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 identified by using Condition Code 51 in UB-04 Field Locator 18-28.

Unplanned ER admissions: Services rendered on the date of an unplanned inpatient admission via the emergency room that lead to admission should be included on the inpatient claim and identified using Admission Type Code 1-Emergency in UB-04 Field Locator 14; ER visits within three days/72 hours that are diagnostically related to the admission are part of the inpatient claim and not separately reimbursed.

Specified exclusions (these may be billed separately): The following outpatient services are excluded from the three-calendar day/72-hour bundling requirement if they are not part of a diagnostic service, an emergency room visit, or related to a procedure which resulted in an inpatient admission: ambulance services; maintenance renal dialysis; chemotherapy; outpatient surgery; radiation therapy; blood/Rx products; physical, occupational and speech therapies (see revenue code guidance in Coding section).

This policy does not apply to hospitals paid under a reimbursement methodology other than DRG and the following hospitals/units: psychiatric hospitals/units; inpatient rehabilitation hospitals/units; long-term care hospitals; children's hospitals; mother/baby claims; cancer hospitals.

Coverage and reimbursement remain subject to member eligibility, benefit limits, claims adjudication edits, and provider scope/fee schedule.

Relevant Coding and Payment Window

Exclusion revenue codesRevenueNot Covered

0540-0549	Ambulance services and related ambulance revenue codes
0330-0339	Radiology - Therapeutic and Chemotherapy administration revenue codes
0380-0399	Blood and blood components/products and administration revenue codes
0250-0259,0631-0637	Pharmacy/Rx and related pharmacy revenue codes
0420-0449	Physical, occupational, speech therapy revenue codes
0820-0889	Maintenance renal dialysis and related revenue codes

Preadmission window (definition)

DefinitionServices performed on the date of inpatient admission or within the prior three calendar days; this includes the immediate 72‑hour period preceding admission.

Billing implicationRelated services within this window are considered part of the inpatient claim and are not separately reimbursable when billed on a separate outpatient facility claim.

Billing and Claim Submission Requirements

Billing Rule

Claim bundling requirement

Related services 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.

Billing Rule

Unrelated outpatient services billing

Any services within the three-calendar day window or immediate 72-hour period that are unrelated to a planned inpatient admission must be billed on a separate outpatient facility claim and identified using Condition Code 51 in UB-04 Field Locator 18-28.

Use Condition Code 51 — Attestation of Unrelated Outpatient Non-Diagnostic Services (UB-04 FL 18-28).

Billing Rule

Key Definitions

3‑Calendar Day Payment Window / 72‑Hour Rule

DefinitionThe 3‑Calendar Day Payment Window/72‑Hour Rule is the day of admission plus the three calendar days preceding an inpatient admission; it includes the immediate 72‑hour period prior to admission (but may be longer than 72 hours).

InclusionIncludes all related diagnostic and non‑diagnostic services performed by the admitting hospital within that period.

Effect on claimsServices that are related to the admission and occur within this window are considered incidental to the inpatient claim and not separately reimbursable when billed on an outpatient facility claim.

Preadmission Testing

DefinitionPreadmission Testing includes any diagnostic or non‑diagnostic services related to an inpatient admission performed on the day of admission or within the prior three calendar days (including the 72‑hour period).

Policy Summary

PayerPremera Bluecross

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

Policy CodePolicy cmi_171642

Change TypeClarifications and additions (non-material)

Effective Date

Next Review Date

Key ActionRelated services within the three-calendar day/72-hour window must be billed on the same claim as the inpatient admission.

SourceLink

On This Page

Unplanned ER admissions

Services provided on the date of an unplanned inpatient admission via the emergency room that lead to admission must be included on the inpatient claim and identified with Admission Type Code 1‑Emergency in UB-04 Field Locator 14; ER visits within three days/72 hours that are diagnostically related to the admission are part of the inpatient claim and not separately reimbursed when billed on an outpatient claim.

Identify the inpatient claim with Admission Type Code 1 — Emergency (UB-04 FL 14).
Do not bill diagnostically related ER visits within three days/72 hours as separate outpatient facility claims.

ProviderApplies to services provided by the admitting hospital in the outpatient setting that are related to the forthcoming inpatient admission.

ReimbursementRelated preadmission testing performed within the window is considered part of the inpatient admission hospital claim and not separately billable when billed on a separate outpatient facility claim.

Diagnostic Services (examples and scope)

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

ExamplesBlood chemistry, diagnostic x‑rays, isotope studies, electrocardiograms (ECGs), pulmonary function tests, thyroid function tests.

PurposePerformed to determine the nature and severity of an ailment or injury; when related to an inpatient admission and done within the 3‑day/72‑hour window, they are considered part of the inpatient claim.

Non‑Diagnostic Services (definition and scope)

Relation to admissionEligibility for inpatient‑claim bundling is determined by whether the service is related to the reason for admission, not by matching diagnosis codes.

Billing implicationWhen related and performed within the preadmission window, non‑diagnostic services are considered part of the inpatient admission and are not separately reimbursable on an outpatient facility claim.