Physicians/Specialists
Facilities/Hospitals
Publication Date: 
2021-03-15

Effective April 20, 2021, the reimbursement policy for Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will indicate that preadmission and preoperative services performed within 72 hours of the patient’s hospital admission (including day of admission/surgery), are not reimbursed separately and are included in inpatient reimbursement. Preadmission and preoperative services are to be billed on the inpatient claim, not separately. 

For surgeries performed in the outpatient hospital setting, preadmission and preoperative services performed within 72 hours of the patient's surgery (including day of surgery), are only reimbursed separately when included on the surgical claim. Preadmission and preoperative services are to be billed on the surgical claim, not separately. 

Preoperative and preadmission services are the necessary laboratory and X-ray tests performed on an outpatient basis prior to a scheduled outpatient surgery or inpatient admission. These necessary services are rendered or accepted by the admitting hospital. 

 

Provider Guidelines for Submitting Claims for Preoperative and Preadmission Services 

  • Preoperative and preadmission services performed at the facility/hospital prior to a scheduled inpatient admission: 

    • Charges for preoperative and preadmission services/testing related to admission/surgery should be included on the same bill as the admission/surgery, whether or not the testing was provided on the date of admission/surgery.  
    • For an inpatient claim, the “From Date” and “Admission Date” may be different, as the “Admission Date” will be the date the patient was admitted to the hospital, while the “From Date” reflects the date on which the preoperative services were performed. 
  • Preoperative and preadmission services performed outside of the hospital prior to a scheduled inpatient admission: 
    • Charges for preoperative services/testing (i.e., radiology services, lab services) performed outside of the facility prior to a scheduled inpatient admission should be billed separately on a CMS-1500 claim form. 

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), State Health Plan (SHP), and Blue Card Inter-Plan Program Host members. 

Prompt processing and payment of claims is contingent upon proper claim submission. Please ensure that your facility is correctly billing for preoperative/preadmission services performed within 72 hours of the patient’s hospital admission or outpatient surgery. We encourage you to review your facility's Blue Cross NC contract to determine your contractual obligations. 

As a reminder, BCBSNC uses multiple systems to process claims and the amounts due may differ based on the specific product as a result of different benefit designs and claim adjudication methodologies. Editing for preadmission and preoperative services has been occurring in parts of our system and the change will bring our systems parity in adjudicating claims.  

 

If you have any questions, please contact the Provider Blue Line at 1-800-214-4844.