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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyWellpoint Inpatient Bundling Update | OpenPayer
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    CurrentWellpointPolicy C-26003

    Inpatient Hospital Inclusive Services - Facility

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    This policy governs facility reimbursement for inpatient hospital services and identifies services included in room-and-board or other facility charges rather than separately reimbursable. It applies to commercial claims submitted by facilities in Florida, Maryland, Texas, and Washington, subject to applicable contracts, laws, benefit terms, and requirements.

    Policy Summary
    PayerWellpoint
    PolicyInpatient Hospital Inclusive Services - Facility
    Policy CodePolicy C-26003
    Change TypeNo material change
    Effective DateFebruary 1, 2027
    Next Review DateNot specified
    Key ActionDo not submit separate reimbursement charges for services included in an inpatient semi-private room and room-and-board charge when reported on the same date of service, unless applicable requirements indicate otherwise.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    4States identified in the policy
    13Inpatient room-and-board inclusive service categories
    3Outpatient service categories inclusive of an inpatient stay
    5

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    Service categories not separately reimbursed with a room or facility fee or qualifying procedure
    0Policy exemptions

    Inclusive Facility Services

    Inpatient Semi-Private Room Inclusive Services

    Services included in an inpatient semi-private room (room and board) charge are not separately reimbursable when reported on the same date of service, including the following:

    INCLUSIVE SERVICES

    • Blood products: splitting, pooling, and thawing
    • DME, including set-up, delivery, and accessories
    • Facility personnel services
    • Feeding kits and supplies
    • Flushes and diluents
    • Nursing services
    • Pharmacy services
    • Pulse oximetry
    • Professional services
    • Radiology guidance: ultrasonic, fluoroscopic, CT, and MRI
    • Routine supplies and equipment
    • Other diagnostic services
    • Therapy services: RT, PT, OT, and ST

    Same-Day Outpatient Services

    Outpatient services billed on the same date of service as an inpatient semi-private room and board charge are considered inclusive of the inpatient stay and are not separately reimbursable.

    INCLUSIVE OUTPATIENT SERVICE CATEGORIES

    • Treatment room
    • Recovery room
    • Clinic services

    Facility Fee and Procedure Bundling

    Separate reimbursement is not allowed when the following services are billed on the same date of service as a room or facility fee, or a procedure other than the administration service by a facility provider:

    BUNDLED SERVICE CATEGORIES

    • Blood product administration
    • Chemotherapy administration
    • Infusion drug administration
    • Insertion of bladder catheters
    • Routine ECG, including professional and technical components and supplies

    Applicable Revenue Codes

    IV therapy and infusion/injection revenue codesRevenue
    0260-0269IV therapy - infusion/injections
    Medical and surgical supplies revenue codesRevenue
    0270-0274Medical/surgical supplies
    0277Medical/surgical supplies
    0279Medical/surgical supplies; excludes implantable devices such as prosthetics, orthotics, and pacemakers
    Chemotherapy, radiopharmaceutical, and blood-product administrationRevenue
    0331Chemotherapy administration - injection
    0343Diagnostic radiopharmaceuticals
    0391Administration, including blood product administration
    Clinic, recovery room, and treatment room revenue codesRevenue
    0510-0529Clinic and freestanding clinic charges
    071XRecovery room
    0760Treatment rooms
    Diagnostic, therapeutic, education, and professional-fee revenue codesRevenue
    0761Other diagnostic services
    0769Other diagnostic services
    0920Other diagnostic services
    0929Other services
    0942Other therapeutic services
    0960-0989Education and training and professional fees

    Claim Submission and Reimbursement Actions

    Billing Rule

    Apply inpatient room-and-board bundling

    Do not submit separate reimbursement charges for services considered inclusive of an inpatient semi-private room and room-and-board charge when reported on the same date of service, unless provider, state, federal, or contractual requirements indicate otherwise.

    • Inclusive services include blood product splitting, pooling, and thawing; DME; facility personnel services; feeding kits and supplies; flushes and diluents; nursing; pharmacy; pulse oximetry; professional services; radiology guidance; routine supplies and equipment; other diagnostic services; and respiratory, physical, occupational, or speech therapy.
    Billing Rule

    Bundle same-day outpatient services

    Treat treatment room, recovery room, and clinic services billed on the same date as an inpatient semi-private room and board charge as inclusive of the inpatient stay and not separately reimbursable.

    Reference Definitions

    General Reimbursement Policy Definitions
    ReferenceGeneral Reimbursement Policy Definitions
    PurposeProvides definitions applicable to Wellpoint reimbursement policies.
    UseConsult the General Reimbursement Policy Definitions when interpreting terms used in this policy.
    Policy Summary
    PayerWellpoint
    PolicyInpatient Hospital Inclusive Services - Facility
    Policy CodePolicy C-26003
    Change TypeNo material change
    Effective DateFebruary 1, 2027
    Next Review DateNot specified
    Key ActionDo not submit separate reimbursement charges for services included in an inpatient semi-private room and room-and-board charge when reported on the same date of service, unless applicable requirements indicate otherwise.
    SourceLink
    On This Page
    Inclusive Facility ServicesApplicable Revenue CodesClaim Submission and Reimbursement ActionsReference Definitions
  1. Apply the bundling rule to same-day treatment room services.
  2. Apply the bundling rule to same-day recovery room services.
  3. Apply the bundling rule to same-day clinic services.
    4. Documentation Required

    Support and submit compliant claims

    Submit compliant industry-standard codes supported by the medical record and follow applicable authorization, medical necessity, benefit, state, federal, and contractual requirements. Claims that do not follow appropriate coding or billing guidelines may be rejected, denied, or subject to payment recovery or recoupment.

    • Use applicable CPT, HCPCS, and/or revenue codes.
    • Ensure billed services and procedures are fully supported in the medical record and/or office notes.
    • Confirm that services meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis.