INPATIENT ONLY PROCEDURES
Governs Priority Health's handling of procedures designated inpatient-only when reported in an outpatient place of service; applies to providers submitting claims to Priority Health.
Added 'Disclaimer' section.
Revision record noting 'No changes made' on June 4, 2025.
Coverage and Billing Criteria
Inpatient-only procedure billing rules
Covered when the following billing rules are met:
ALL of the following
- The procedure code is not designated by CMS with status indicator 'C' (inpatient only).
Procedure codes with CMS status 'C' reported in non-inpatient places of service will be denied.
- If the procedure code has CMS status indicator 'C', do not report it for any place of service other than inpatient.
Claims will be denied and returned when a procedure code with status indicator 'C' is reported in any place of service other than inpatient.
- Authorization and medical necessity requirements appropriate to the procedure, diagnosis and frequency must be met.
An authorization is not a guarantee of payment; proper billing, coding and documentation are required.
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