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Services Bundled into Inpatient / Outpatient Stays

Commercial Reimbursement Policy

Origination: 06/2021

Last Review: 03/2024

Description

Routine services, supplies, and equipment are included within the overall room and board or room care charges of inpatient and outpatient stays.

Billed charges for hospital routine services, supplies, equipment and items constitute unbundled, fragmented or otherwise duplicative charges which should reasonably be included in another charge.

Surgical rooms include, but are not limited to, surgical suites, major and minor treatment rooms, endoscopy labs, cardiac cath labs, X-ray, pulmonary and cardiology procedural rooms.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will limit reimbursement for routine services, supplies, and equipment according to the criteria outlined in this policy.

Reimbursement Guidelines

Routine services, supplies, and equipment are included in a daily hospital service charge and are not separately reimbursable. Routine surgical services and supplies associated with an outpatient surgical procedure are not separately reimbursable.

Any supplies, items, and services that are necessary or otherwise integral to the provision of a specific service and/or to the delivery of services in a specific location are considered routine services and not separately reimbursable in the inpatient and outpatient settings.

Non-reimbursable services may result in line-item reductions.

All items and supplies that may be purchased over-the-counter are not separately reimbursable.

Reusable items, supplies, and equipment that are provided to all patients admitted to a given treatment area or unit (i.e. NICU, Burn Unit, PACU, Medical/Surgical) are not separately reimbursable.

All reusable items, supplies, and equipment that are provided to all patients receiving the same service (i.e., an Ambu bag during resuscitation) are not separately reimbursable. The operating room (OR) charge may be based on time or on a procedural basis. It is inappropriate to include both a time based and procedural based OR fee.

Anesthesia supplies are not separately reimbursable when billed with anesthesia time-based charge. 

Blue Cross NC’s inpatient reimbursement is considered all-inclusive.

Non-professional services provided to a Blue Cross NC member by an entity other than the admitting facility while the member is registered as an inpatient at an acute care hospital, long term acute care hospital, skilled nursing facility, psychiatric hospital/facility, substance abuse hospital/facility or a residential treatment center/facility are not separately billable to Blue Cross NC.

The tables below are examples and do not represent an all-inclusive list: 
Not Separately Reimbursable Routine Eqipment
Ambu bagFansPatient room furniture; manual, electric, semielectric beds
Aqua pad motorFeeding pumpsPCA pump 
Arterial pressure monitors (inclusive of Critical Care room charges only)Flow metersPen light or other flashlight
Auto Syringe Pump FootboardPICC line (reusable equipment associated with PICC line placement) 
Automatic thermometers and blood pressure machines GlucometersPill pulverizer
Bed scalesGuest bedsPressure bags or pressure infusion equipment
Bedside commode  Heating or cooling pumps Radiant warmer
Blood pressure cuffsHemodynamic monitors (inclusive of Critical Care room charges only) Sitz bath
Blood warmers Humidifiers Stethoscope 
Cardiac monitorsInfant warmerSuction pumps 
CO2 monitorsInjections (therapeutic, prophylactic, or diagnostic) Telephone
Crash cartIV pumps; single and multiple lines, tubingTelevisions
Defibrillator and paddlesNebulizersTraction equipment
Digital recording equipment and printoutsOverhead framesTransport isolette
DinamapOver-bed tablesWall suction, continuous or intermittent
Emerson pumpsOximeter/Oxisensors – single use or continuous 
Not Separately Reimbursable Routine Services 
Administration of blood or any blood product by nursing staff (does not include tubing, blood bank, preparation, etc.) Incontinence care Patient and family education and counseling
Administration or application of any medicine, chemotherapy, and/or IV fluids.Injections (therapeutic, prophylactic or diagnostic)PICC Line Insertions (Routine Nursing Service)
Arterial and venipunctureInsert, discontinue, and/or maintain nasogastric tubesPoint-of-Care (POC) Testing (ABG’s, Glucose, Electrolytes, Troponin, etc.)
Assisting patient onto bedpan, bedside commode or into bathroomIntubation Preoperative care 
Bathing of patients Maintenance and flushing of Jtubes, PEG tubes, and feeding tubes of any kind Respiratory therapy services
Bedside Glucose monitoringMaintenance of oxygen administration equipmentSet up and/or take-down of: IV pumps, flow meters, heating or cooling pumps, over-bed frames, oxygen, feeding pumps, TPN, traction equipment, monitoring equipment
Bedside tracheostomy care and changing of cannulasMedical record documentation Shampoo hair
Body preparation of deceased patientsMixing, preparation of, or dispensing of any medication, IV fluids, total parenteral nutrition (TPN), or tube feedings Single determination or continuous pulse oximetry monitoring.
Cardiac rehabilitation (during inpatient stay)Monitoring and maintenance of peripheral or central IV lines and sites – to include site of care, dressing changes and flushesStart and/or discontinue IV lines 
Cardiopulmonary resuscitation (CPR); including the management/participation in cardiopulmonary arrest event. Obtaining and recording of blood pressure, temperature, perspiration, pulse, pulse oximetryMonitoring of cardiac monitors; CVP (central venous pressure) lines; Swan Ganz lines/pressure reading; arterial lines/readings; pulse oximeters; cardiac output, pulmonary arterial pressure.Suctioning or lavage of patients
Changing of dressing, bandages and/or ostomy appliances Neurological status checksTransporting, ambulating, range of motion, transfer to and from bed or chair
Changing of linens and patient gownsNursing careTurning and weighing patients 
Chest tube maintenances, dressing change, discontinuation Obtaining and recording vital signs (blood pressure, temperature, respiration, pulse, pulse oximetry)Wound care (during inpatient stay) 
Enterostomal servicesNo separate charge will be allowed for callback, emergency, standby, urgent attention, ASAP, STAT, or portable fees.  
Feeding of patientsOral care  
Not Separately Reimbursable Routine Supplies
Admission, hygiene, and or comfort kitsIV (intravenous) arm boardsSaline solutions
Alcohol swabsIV Solutions 500cc or less (used for flushes or to mix medications)Shampoo
Arterial blood gas kits LotionSharps container
Baby powderLubricantShaving cream
Band-aidsMasks (patient or staff) Skin cleansing liquid 
BasinMeal traysSoap
Bedpan, regular or fracture panMeasuring pitcherSocks/slippers 
Blood tubesMid-stream urine kits Specipan 
Cotton balls (sterile or nonsterile)Mouth care kitsSputum trap 
DeodorantMouthwashSyringes
DrapesNeedlesTape
Dressings and bandagesOdor eliminator/ Room deodorizerThermometers
Emesis basin Oral swabs Tissues
Flushes (Heparin, Saline, water, etc.)Oxygen Toilet paper
Gloves (patient or staff) Oxygen masksTongue depressors
Glycerin swabsPillowsToothpaste
Heat light or heating padPreparation kitsTubing (IV, suction, equipment, etc.) 
Ice packsRazors Urinal
Irrigation solutions RestraintsWater pitcher
Items used to obtain a specimen or complete a diagnostic or therapeutic procedureReusable sheets, blankets, pillowcases, draw sheets, underpads, washcloths and towels 
Not Separately Reimbursable Routine Critical Care Services 
Daily Ventilator, CPAP, and/or BiPAP ManagementRespiratory therapy services
Facility service charge for critical care includes the routine tables for Equipment, Services, and Supplies Special equipment (dinemapp, swan ganz, pressure monitor, pressure transducer monitor, oximetry monitor, etc.)
Nursing CareTelemetry
Not Separately Reimbursable Routine Surgical Services and Supplies
Air conditioning and filtrationFracture tables Robotic surgical systems
All reusable instruments charged separatelyGrounding padsRoom heating/cooling and monitoring equipment
All services rendered by RN’s, LPN’s, scrub technicians, surgical assistants, orderlies, and aidesHemochronRoom set-ups of equipment and supplies
Anesthesia equipment, supplies and monitorsHemoconcentratorSaline slush machine
Any automated blood pressure equipmentHemostatic agents (Tisseel, FloSeal, etc) Skin closure devices (sutures, staples, etc.)
Cardiac monitors Instrument traysSolution warmer
Cardiopulmonary bypass equipmentLaparoscopes, bronchoscopes, endoscopes, and accessories Surgeons’ loupes or other visual assisting devices
CO2 monitorsLights, light handles, light cords, fiber optic microscopesSurgical clips and staplers (reloads, etc.) 
Crash cartsLocal Anesthesia (long or short acting)Surgical drill 
Digital recording equipment and printoutsMonopolar and bipolar electrosurgical/bovie and cautery (equipment and handpieces) Transport monitor
DinamapNegative pressure wound therapy (vacuum assisted closure devices) Video camera and tape
Disposable surgical supplies (trocars, blades, gowns, guide wires, etc.)Obtaining laboratory specimensWall suction equipment
Facility service charge for surgical services includes the routine tables for Equipment, Services, and SuppliesPower equipmentX-ray film
Flat or Per day supply feesReusable surgical equipment, instruments and trays 
Not Separately Reimbursable Respiratory Services
Bedside pulmonary mechanics Intubation assistanceSleep apnea monitoring system (setup, screening and monitoring)
Chest manipulation (external chest wall oscillation)Mini bronchoalveolar lavage testSpontaneous breathing screen/trial
Cleaning of internal or external components of ventilatorMonitoring during transport or for special procedure Static pressure/volume loop
Diaphragmatic EMG sensor catheter placementNasal cannula systemSupplemental oxygen (systemsetup, patient/systemassessment, equipment change) 
End tidal carbon dioxide systemsetup and/or monitoring (expired gas determination)Oral careSurfactant administration 
Equipment change (all noninvasive and invasive) from one type of respiratory assist device to anotherOximetry check and/or trendingTherapeutic ventilatory maneuver (recruitment maneuver)
Esophageal balloon catheter placementPlacement or change of in-line suction catheterTracheostomy tube care
Esophageal pressure monitoring Positive expiratory pressure (PEP) breathing device, instruction and/or therapyTranscutaneous monitoring (initial system setup and/or monitoring) 
FRC (functional residual capacity) determinationRespiratory assessment and/or respiratory protocol assessmentVent-acquired pneumonia prevention activities
Gas cylinder changeRespiratory therapy educationVentilator circuit change
Heliox ventilation Saline diluentsVentilator transport
Incentive spirometry (set up or demonstration for patient at bedside)Setting or device adjustment (emergent or non-emergent, invasive or non-invasive)Ventilator weaning and extubation 

Rationale

Similar to CMS and correct coding initiatives, Blue Cross NC will not separately reimburse for routine services, supplies, and equipment as they are deemed to be included in the daily hospital service charge.

Per CPT and CMS guidelines, heparin flushes (J1642), saline flushes (A4216), IV flushes of any type, and solutions used to dilute or administer substances, drugs, or medications are included in the administration service. These items are considered supplies and are not eligible for separate reimbursement. Although J1642 (Injection, heparin sodium, (heparin lock flush), per 10 units) describes heparin flushes, heparin flushes are not considered a “drug” and are not separately reimbursable.

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

Blue Cross NC Provider Manual Provider Blue Book

CMS Provider Reimbursement Manual, Determination of Cost of Services to Beneficiaries, Chapter 22, Section 2202.6 CMS Chapter 22

History
DateDescription
6/9/21Content extracted from provider manual and developed into policy to clarify and summarize routine services, supplies, and equipment included in a daily hospital service charge. Blue Cross Blue Shield North Carolina (Blue Cross NC) will limit reimbursement for routine services, supplies, and equipment according to the criteria outlined in this policy. Notification on 6/9/2021 for effective date 8/10/2021 (eel)
9/21/2021Removed ventilator management items from Critical Care and Respiratory grids. (eel) 
12/30/2021Routine policy review. Medical Director approved. Based on existing provider manual language, “Cardiac rehabilitation (during inpatient stay)” added to routine service list. (eel)
12/31/2022Routine policy review. Added clarifying language about line-items reductions under Reimbursement Guidelines. Medical Director approved. (cjw)
4/21/2023Added verbiage to Reimbursement guidelines section to clarify inpatient reimbursement being considered all-inclusive. Clarified Rationale section. MD Approved. Notification on 4/21/2023 for effective date 6/30/2023. (eel)
6/30/2023Clarification added to Routine Surgical grid “Skin closure devices” and “Surgical Clips and Staplers“. Clarification added to Routine Respiratory “PEP instruction and/or therapy”. No change to policy intent. (eel) 
8/1/2023Respiratory therapy services added to Not Separately Reimbursable Routine Services table. Nursing care added to Not Separately Reimbursable Routine Critical Care Services table. Medical Director approved. Notification on 8/1/2023 for effective date 10/1/2023. (tlc)
3/12/2024Clarification added to routine services and supplies grids for “PICC line insertions”, “Point-of-Care testing”, “IV solutions 500 cc or less” and “daily ventilator, CPAP, and/or BiPAP management”. No change to policy intent. (ss)

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.

Disclosures:

Reimbursement policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and Blue Cross NC reserves the right to review and revise its medical and reimbursement policies periodically.

Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

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