Description

Preadmission and preoperative services are often necessary to ensure the health and safety of a member before they undergo surgery or an inpatient admission. A wide range of examinations and diagnostics may be considered preadmission or preoperative services, including, but not limited to X-ray, laboratory tests, and EKGs.

Centers for Medicare and Medicaid Services (CMS) “Three-day window” rule considers these related preadmission and preoperative services incidental to the subsequent facilities admission or surgical payment.

CMS “Three‐day window” definition:

“Defined as three (3) days prior to and including the date the beneficiary is admitted as an inpatient. For example, if a beneficiary is admitted as an inpatient on Wednesday, then Sunday, Monday, Tuesday, or Wednesday is part of the three‐day window. Under the payment window policy, a hospital (or an entity that is wholly owned or wholly operated by the hospital) must include on the claim for a beneficiary's inpatient stay, the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient nondiagnostic services that are furnished to the beneficiary during the 3-day payment window.” (Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 90.7 and 90.7.1)

Diagnostic services (including clinical diagnostic laboratory tests) provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment. (Medicare Claims Processing Manual, Pub. 100-04, Chapter 3, Section 40.3)

This policy applies to facility claims. Please refer to global allowance rules in the Bundling Guidelines policy for professional claims.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will limit reimbursement for preadmission and preoperative services according to the criteria outlined in this policy.

Reimbursement Guidelines

Place of Service

• Inpatient 
  • Preadmission and preoperative services performed at the same hospital system with the same federal tax ID.
    • Within 72 hours – date of admission/surgery included
      • Not separately reimbursable, included in inpatient payment 
• Outpatient 
  • Preoperative services performed at the same facility 
    • Within 72 hours – date of surgery included 
      • Separately reimbursable when included on surgical claim 

Rationale

Based on CMS guidance, preadmission and preoperative services performed by the admitting hospital within seventy-two (72) hours of inpatient admission, including the date of admission, are deemed to be included in the subsequent inpatient admission payment.

Please refer to the “Pre-operative / pre-admission services” section in Provider Manual for more information related to claim filing, including for ambulatory surgery centers (ASC).

Additionally, we encourage you to review your facility's Blue Cross NC contract regarding preoperative/preadmission testing for scheduled admissions/surgeries to determine your contractual obligations. 

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.

Related policy

Bundling Guidelines

References

Medicare Claims Processing Manual, Global Surgery 

Blue Cross North Carolina Provider Blue Book

History

4/20/21 New policy developed. Blue Cross Blue Shield North Carolina (BCBSNC) will limit reimbursement for preadmission and preoperative services according to the criteria outlined in this policy. Medical Director review 3/2021. (eel)

12/30/21 Routine policy review. Medical Director approved. (eel)

12/31/2022 Routine policy review. Minor revisions only. (ckb)

6/23/2023 Z01.89 added and Fed Tax ID criteria specified for Inpatient. Medical Director approved. Notification on 6/30/2023 for effective date 8/29/2023. (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy