Currentpriority healthPolicy N/A

Inpatient and Outpatient Incidental Services and Supplies

Defines Priority Health's reimbursement rules for services, supplies and equipment considered incidental or inclusive to inpatient and outpatient facility charges and which items are not separately payable; applies to providers and facilities submitting claims to Priority Health.

Policy Summary

Payerpriority health

PolicyInpatient and Outpatient Incidental Services and Supplies

Policy CodePolicy N/A

Change TypeAdded guidance and terminology updates

Effective DateAug 1, 2024

Next Review DateMar 1, 2025

Key ActionClaims with incidental/inclusive items that don't follow guidelines will be rejected and must be rebilled or adjusted.

SourceLink

POLICY UPDATE CHANGES

Added Global surgery surgical supplies guidance denying specific surgical dressing HCPCS codes billed in the provider's office (POS 11) and clarifying they are incident to professional services and not separately payable.

Added 'All peripheral and central line supplies' under Routine Medical Supplies, Medical Equipment and Facility Charges to clarify inclusivity.

Added 'Post void residuals' to the list of items/supplies associated with facility charges.

Updated language to replace references to 'unbundling' with 'incidental services and supplies' and renamed the policy accordingly.

multiple listslists of items/supplies considered incidental or included

specific HCPCS codessurgical dressing codes denied in POS 11

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Incidental and Included Services

Incidental and included services/supplies

Priority Health does not reimburse separately for services, supplies, or equipment that are incidental to a primary service, integral to a defined procedure, or included in facility/room charges. Examples follow (not all‑inclusive).

Covered when items are NOT separately reimbursable because they are incidental, integral, or included in facility/room charges

Incidental

The cost of incidental services when performed with a more comprehensive primary service is not separately payable; these services are clinically integral to the expected outcome of the primary service and may not be reported separately, including technical charges for purchase, rental, and/or maintenance of equipment.

Integral procedures

Most HCPCS/CPT code defined procedures include services that are integral to them; services integral to a HCPCS/CPT procedure are included in that procedure and are not separately reimbursable when performed as part of another procedure.

Line‑level review

Claims are reviewed at the line level to detect when an incidental service or a component of a more comprehensive service is billed (for example, revenue codes submitted for routine supplies/equipment/nursing care that are considered a component of room and board charges).

Included in customary room/board or facility charge

Items determined to be included in customary daily room and board charges or included in the facility charge for the primary service are not separately reimbursable.

Examples — Basic hospital room daily charges (not all‑inclusive)

Equipment, services, and supplies associated with personal care, personnel performing nursing or technical services, and items associated with room furnishing across areas such as ED, observation, surgical suites, critical care, cath lab, neonatal, and others.

Examples — Routine medical supplies (not all‑inclusive)

Alcohol swabs; all peripheral and central line supplies; blood gas kits; band‑aids; basin; bedpan; blood tubes; cotton balls; personal care items (deodorant, razors, shampoo, etc.); drapes; masks, gloves, gowns by staff/family; skin cleansing liquids; heating light or pad; ice packs; needles; oral swabs; oxygen masks; PICC line supplies; prep kits; restraints; blankets, sheets, pillows, towels; saline/irrigation solutions; sharps containers; tools/items to obtain specimens or perform procedures; syringes; tape; thermometers; toilet paper; tongue depressors; urinals.

Examples — Medical equipment (not all‑inclusive)

All peripheral and central line supplies; ambu bag; arterial pressure monitors; auto syringe pump; bed scales; bedside commodes; blood pressure cuffs; cardiac monitors; crash cart; defibrillators; feeding pumps; glucometers; IV pumps and tubing; nebulizers; oximeters and sensors; PICC line reusable equipment associated with placement; transport isolette; wall suction; and other devices commonly supplied during procedures and hospital stays.

Examples — Facility charges and nursing/clinical services (not all‑inclusive)

Administration or application of medications/chemotherapy/IV fluids; administration of blood or blood products by nursing staff; arterial/venipuncture blood collection; bedside assistance; assisting physician or licensed personnel during procedures; bathing; changing of dressing/bandages/ostomy supplies or appliances; maintenance of chest tubes and IV lines (including dressing changes, flushes, and care of insertion site); point of care testing; post void residuals; nursing care; monitoring (vitals, telemetry, oximetry); respiratory therapy services and other routine facility services.

Surgical dressing denials in POS 11

Claims with the listed surgical dressing HCPCS codes billed in the provider office (POS 11) will be denied as these are considered incident to the professional service and not separately payable.

Claims with surgical dressing HCPCS codes A6010-A6011, A6021-A6025, A6196-A6224, A6228-A6248, A6250-A6262, A6266, A6402-A6404, A6407, A6413, A6441-A6456 billed in provider office (POS 11) will be denied because, per CMS policy, surgical dressings applied by a physician as part of a professional service are considered incident to that professional service and are not separately payable.

Coding and Line-Level Review

Surgical dressing HCPCS codes (denied POS 11)HCPCSNot Covered

A6010-A6011	Surgical dressings denied when billed in provider office (POS 11); considered incident to professional services per CMS
A6021-A6025	Surgical dressings denied when billed in provider office (POS 11); considered incident to professional services per CMS
A6196-A6224	Surgical dressings denied when billed in provider office (POS 11); considered incident to professional services per CMS
A6228-A6248	Surgical dressings denied when billed in provider office (POS 11); considered incident to professional services per CMS
A6250-A6262	Surgical dressings denied when billed in provider office (POS 11); considered incident to professional services per CMS
A6266	Surgical dressings denied when billed in provider office (POS 11); considered incident to professional services per CMS
A6402-A6404	Surgical dressings denied when billed in provider office (POS 11); considered incident to professional services per CMS
A6407	Surgical dressings denied when billed in provider office (POS 11); considered incident to professional services per CMS
A6413	Surgical dressings denied when billed in provider office (POS 11); considered incident to professional services per CMS
A6441-A6456	Surgical dressings denied when billed in provider office (POS 11); considered incident to professional services per CMS

inv-04: line-level incidental detection

Review levelClaims are reviewed at the line level to detect incidental or component services that should be included in a comprehensive code

What is detectedIncidental services or components of a more comprehensive service billed separately (including revenue codes for routine supplies/equipment/nursing care)

Action on non‑compliant linesClaim lines not following guidelines will be rejected and must be rebilled or adjusted

PurposeTo identify items included in room/board or facility charges and prevent separate reimbursement

What Providers Must Do

Prior Authorization

Authorization notice

Authorization and medical necessity requirements remain in effect for all services. An authorization does not guarantee payment if billing, coding, documentation, or policy requirements are not met. Providers must use industry-standard compliant codes (CPT, HCPCS, revenue codes) reported only when the service was performed and fully documented to the highest level of specificity. Failure to document services or items supplied will result in denial. Payment-integrity pre- or post-claim reviews may be performed to validate billing and coding accuracy and to prevent fraud, waste, and abuse.

Authorization depends on clinically appropriate procedure, diagnosis, and frequency specifics.
Authorizations do not supersede coding, billing, or reimbursement rules.
Services must be documented in the medical record to support billed codes; lack of documentation may lead to denial.

Denial Risk

Claims handling

Key Definitions

inv-07: Incidental — definition

DefinitionIncidental: The cost of incidental services when performed with a more comprehensive primary service is not separately payable; these services are clinically integral to the expected outcome of the primary service and may not be reported separately.

ExamplesTechnical charges for purchase, rental, and/or maintenance of equipment when integral to the primary service are considered incidental and not separately reimbursable.

Policy implicationItems/services deemed incidental are excluded from separate reimbursement and claims not following guidelines will be rejected.

inv-08: Integral procedures

DefinitionIntegral procedures/services: Services included in HCPCS/CPT‑defined procedures and not separately reimbursable when performed as part of another procedure.

Reporting note