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Outpatient Services Prior to Admission or Same-Day Surgery

Reimbursement Policy:

Outpatient (OP) Services Prior to Admission or Same-Day Surgery (SDS)

Effective Date:

January 1, 2003

Last Revised Date:

January 26, 2023

Purpose:

This policy outlines our guidelines for the reimbursement of outpatient services prior to an admission or same-day surgery.

Scope:

All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

Outpatient services prior to an admission or same-day surgery include, but are not limited to, the following:

  • Outpatient diagnostic services,
  • Pre-admission testing,
  • Admission-related outpatient non-diagnostic services,
  • Observation services,
  • Emergency room services, and
  • COVID-19 testing for all inpatient admissions and same-day surgery services.

Policy:

Horizon BCBSNJ considers the reimbursement of all medically necessary outpatient services rendered prior to an admission or same-day surgery as included in the reimbursement the facility receives for the inpatient stay or same-day surgery if those services are: (1) related to the member’s inpatient stay or same-day surgery and (2) performed on the date of admission or same-day surgery, or within three calendar days prior to the date of admission or same-day surgery.

For example, if a member is admitted as an inpatient on a Wednesday, any related outpatient services prior to the admission performed on that Wednesday, or on the preceding Tuesday, Monday, or Sunday, will not be separately reimbursed because reimbursement for such services is included in the reimbursement for the inpatient admission.

If the non-diagnostic outpatient services rendered are not related to the inpatient admission or same-day surgery, the facility must report condition code 51 (attestation of unrelated outpatient non-diagnostic services) on the outpatient claim in order for such services to be separately reimbursable.

Outpatient maternity services prior to an admission or same-day surgery are excluded from this policy and will be reimbursed separately from the inpatient admission or same-day surgery, despite being related to the member’s inpatient stay and performed within three calendar days prior to the date of admission or same-day surgery. The facility must report condition code B3 (attestation of maternity related outpatient non-diagnostic services) on the outpatient claim in order for such services to be separately reimbursable.

Procedure:

Horizon will not consider for reimbursement any outpatient services prior to an admission or same-day surgery performed on the date of an inpatient admission or same-day surgery, or within three calendar days prior to the date of an admission or same-day surgery, when such outpatient services are related to the inpatient admission or same-day surgery and are submitted by an admitting facility or entity that is associated or affiliated with the admitting facility (e.g., part of hospital system, affiliated ambulatory surgery center, etc,).

Horizon BCBSNJ will consider for reimbursement any non-diagnostic outpatient services prior to an admission or same-day surgery performed on the date of an inpatient admission or same-day surgery, or within three calendar days prior to the date of admission or same-day surgery, when such outpatient services are (1) not related to the inpatient admission or same-day surgery and (2) billed using condition code 51.

Horizon BCBSNJ will consider for reimbursement any maternity-related outpatient services prior to a pregnancy-related admission or same-day surgery.

Ambulance services provided on the day of, or within three calendar days prior to, an admission or same-day surgery are considered separately reimbursable.

Horizon reserves the right to review medical documentation when determining the proper application of this policy to a submitted claim.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:

04/15/2011: Policy approved

02/06/2012: Update to SDS criteria to allow separate reimbursement for same claim/same DOS PAT services.

07/09/2014: Revised and reformatted content for clarity per Legal.

07/30/2015: Removed "by an entity owned or operated by the hospital…" from Policy: section Revised Procedure: section, Paragraph 2 "admissions may be…"

08/04/2020: Added reference to COVID-19 testing and "associated or affiliated entity" language within the Policy section.

05/24/2021: Updated to remove from Definition and policy sections the statement: "related to a patient’s planned inpatient admission or same day surgery". Removed from Procedure section second paragraph, "Outpatient Services that are not…"

1/26/2023: Policy name change from Pre-Admission Testing to "Outpatient (OP) Services Prior to Admission or Same-Day Surgery". Policy updated to include OP services as inclusive to Admission or Same Day Surgery when OP services are rendered within 3 calendar days of admission or same day surgery

Policy058_v7.0_01272023