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 services, supplies, and equipment are considered incidental and are not eligible for separate reimbursement.
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 Equipment
- Ambu bag
- Aqua pad motor
- Arterial pressure monitors (inclusive of Critical Care room charges only)
- Auto Syringe Pump
- Automatic thermometers and blood pressure machines
- Bed scales
- Bedside commode
- Blood pressure cuffs
- Blood warmers
- Cardiac monitors
- CO2 monitors
- Crash cart
- Defibrillator and paddles
- Digital recording equipment and printouts
- Dinamap
- Emerson pumps
- Fans
- Feeding pumps
- Flow meters
- Footboard
- Glucometers
- Guest beds
- Heating or cooling pumps
- Hemodynamic monitors (inclusive of Critical Care room charges only)
- Humidifiers
- Infant warmer
- Injections (therapeutic, prophylactic, or diagnostic)
- IV pumps; single and multiple lines, tubing
- Nebulizers
- Over-bed tables
- Overhead frames
- Oximeter/Oxisensors – single use or continuous
- Patient room furniture; manual, electric, semielectric beds
- PCA pump
- Pen light or other flashlight
- PICC line (reusable equipment associated with PICC line placement)
- Pill pulverizer
- Pressure bags or pressure infusion equipment
- Radiant warmer
- Sitz bath
- Stethoscope
- Suction pumps
- Telephone
- Televisions
- Traction equipment
- Transport isolette
- Wall suction, continuous or intermittent
Not Separately Reimbursable Routine Services
- Administration of blood or any blood product by nursing staff (does not include tubing, blood bank, preparation, etc.)
- Administration or application of any medicine, chemotherapy, and/or IV fluids
- Arterial and venipuncture
- Assisting patient onto bedpan, bedside commode, or into bathroom
- Bathing of patients
- Bedside glucose monitoring
- Bedside tracheostomy care and changing of cannulas
- Body preparation of deceased patients
- Cardiac rehabilitation (during inpatient stay)
- Cardiopulmonary resuscitation (CPR), including the management/participation in cardiopulmonary arrest event; obtaining and recording blood pressure, temperature, perspiration, pulse, and pulse oximetry
- Changing of dressings, bandages, and/or ostomy appliances
- Changing of linens and patient gowns
- Chest tube maintenance, dressing changes, and discontinuation
- Enemas
- Enterostomal services
- Feeding of patients
- Incontinence care
- Injections (therapeutic, prophylactic, or diagnostic)
- Insert, discontinue, and/or maintain nasogastric tubes
- Intubation
- Maintenance and flushing of J-tubes, PEG tubes, and feeding tubes of any kind
- Maintenance of oxygen administration equipment
- Medical record documentation
- Mixing, preparation, or dispensing of any medication, IV fluids, total parenteral nutrition (TPN), or tube feedings
- Monitoring and maintenance of peripheral or central IV lines and sites, including site care, dressing changes, and flushes
- Monitoring of cardiac monitors; CVP (central venous pressure) lines; Swan-Ganz lines/pressure readings; arterial lines/readings; pulse oximeters; cardiac output; pulmonary arterial pressure
- Neurological status checks
- No separate charge will be allowed for callback, emergency, standby, urgent attention, ASAP, STAT, or portable fees
- Nursing care
- Obtaining and recording vital signs (blood pressure, temperature, respiration, pulse, pulse oximetry)
- Obtaining finger-stick blood sugars; blood samples from venous sticks, central line catheters, or PICC lines; arterial draws; urine specimens; stool specimens; sputum specimens; and body fluid specimens
- Oral care
- Patient and family education and counseling
- PICC line insertions (routine nursing service)
- Point-of-Care (POC) testing (ABGs, glucose, electrolytes, troponin, etc.)
- Preoperative care
- Respiratory therapy services
- Set up and/or take down IV pumps, flow meters, heating or cooling pumps, over-bed frames, oxygen equipment, feeding pumps, TPN, traction equipment, and monitoring equipment
- Shampoo hair
- Single determination or continuous pulse oximetry monitoring
- Start and/or discontinue IV lines
- Suctioning or lavage of patients
- Transporting, ambulating, range of motion, and transfers to and from bed or chair
- Turning and weighing patients
- Urinary catheterization
- Wound care (during inpatient stay)
Not Separately Reimbursable Routine Supplies
- Admission, hygiene, and/or comfort kits
- Alcohol swabs
- Arterial blood gas kits
- Baby powder
- Band-Aids
- Basin
- Bedpan (regular or fracture pan)
- Blood tubes
- Cotton balls (sterile or nonsterile)
- Deodorant
- Drapes
- Dressings and bandages
- Emesis basin
- Flushes (heparin, saline, water, etc.)
- Gloves (patient or staff)
- Glycerin swabs
- Gown (patient or staff)
- Heat lamp or heating pad
- Ice packs
- Irrigation solutions
- Items used to obtain a specimen or complete a diagnostic or therapeutic procedure
- IV (intravenous) arm boards
- IV solutions 500 cc or less (used for flushes or to mix medications)
- Lotion
- Lubricant
- Masks (patient or staff)
- Meal trays
- Measuring pitcher
- Mid-stream urine kits
- Mouth care kits
- Mouthwash
- Needles
- Odor eliminator/room deodorizer
- Oral swabs
- Oxygen
- Oxygen masks
- PICC (peripherally inserted central catheter) line
- Pillows
- Preparation kits
- Razors
- Restraints
- Reusable sheets, blankets, pillowcases, draw sheets, underpads, washcloths, and towels
- Saline solutions
- Shampoo
- Sharps container
- Shaving cream
- Skin cleansing liquid
- Soap
- Socks/slippers
- Specipan
- Sputum trap
- Syringes
- Tape
- Thermometers
- Tissues
- Toilet paper
- Tongue depressors
- Toothbrush
- Toothpaste
- Tubing (IV, suction, equipment, etc.)
- Urinal
- Water pitcher
Not Separately Reimbursable Routine Critical Care Services
- Daily Ventilator, CPAP, and/or BiPAP Management
- Facility service charge for critical care includes the routine tables for Equipment, Services, and Supplies
- Nursing Care
- Respiratory therapy services
- Special equipment (dinemapp, swan ganz, pressure monitor, pressure transducer monitor, oximetry monitor, etc.)
- Telemetry
Not Separately Reimbursable Routine Surgical Services and Supplies
- Air conditioning and filtration
- All reusable instruments charged separately
- All services rendered by RNs, LPNs, scrub technicians, surgical assistants, orderlies, and aides
- Anesthesia drugs, equipment, supplies, and monitors
- Any automated blood pressure equipment
- Cardiac monitors
- Cardiopulmonary bypass equipment
- CO₂ monitors
- Crash carts
- Digital recording equipment and printouts
- Dinamap
- Disposable surgical supplies (trocars, blades, gowns, guide wires, etc.)
- Facility service charge for surgical services includes the routine tables for Equipment, Services, and Supplies
- Flat or per-day supply fees
- Fracture tables
- Grounding pads
- Hemochron
- Hemoconcentrator
- Hemostatic agents (Tisseel, FloSeal, etc.)
- Instrument trays
- Laparoscopes, bronchoscopes, endoscopes, and accessories
- Lights, light handles, light cords, and fiber optic microscopes
- Local anesthesia (long- or short-acting)
- Monopolar and bipolar electrosurgical/Bovie and cautery equipment (including handpieces)
- Negative pressure wound therapy (vacuum-assisted closure devices)
- Obtaining laboratory specimens
- Power equipment
- Reusable surgical equipment, instruments, and trays
- Robotic surgical systems
- Room heating/cooling and monitoring equipment
- Room set-ups of equipment and supplies
- Saline slush machine
- Skin closure devices (sutures, staples, etc.)
- Solution warmer
- Surgeons’ loupes or other visual-assisting devices
- Surgical clips and staplers (including reloads)
- Surgical drill
- Transport monitor
- Video camera and tape
- Wall suction equipment
- X-ray film
Not Separately Reimbursable Respiratory Services
- Bedside pulmonary mechanics
- Chest manipulation (external chest wall oscillation)
- Cleaning of internal or external components of ventilators
- Diaphragmatic EMG sensor catheter placement
- End-tidal carbon dioxide system setup and/or monitoring (expired gas determination)
- Equipment change (all non-invasive and invasive) from one type of respiratory assist device to another
- Esophageal balloon catheter placement
- Esophageal pressure monitoring
- FRC (functional residual capacity) determination
- Gas cylinder change
- Heliox ventilation
- Incentive spirometry (setup or demonstration for patient at bedside)
- Intubation assistance
- Mini bronchoalveolar lavage test
- Monitoring during transport or for special procedures
- Nasal cannula system
- Oral care
- Oximetry check and/or trending
- Placement or change of in-line suction catheter
- Positive expiratory pressure (PEP) breathing device instruction and/or therapy
- Respiratory assessment and/or respiratory protocol assessment
- Respiratory therapy education
- Saline diluents
- Setting or device adjustment (emergent or non-emergent, invasive or non-invasive)
- Sleep apnea monitoring system (setup, screening, and monitoring)
- Spontaneous breathing screen/trial
- Static pressure/volume loop
- Supplemental oxygen (system setup, patient/system assessment, equipment change)
- Surfactant administration
- Therapeutic ventilatory maneuver (recruitment maneuver)
- Tracheostomy tube care
- Transcutaneous monitoring (initial system setup and/or monitoring)
- Ventilator circuit change
- Ventilator transport
- Ventilator weaning and extubation
- Vent-acquired pneumonia prevention activities
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
Anesthesia Services, Professional
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
| Date | Revision |
|---|---|
| 6/9/21 | Content 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) |
| 9/21/2021 | Removed ventilator management items from Critical Care and Respiratory grids. (eel) |
| 12/30/2021 | Routine policy review. Medical Director approved. Based on existing provider manual language, “Cardiac rehabilitation (during inpatient stay)” added to routine service list. (eel) |
| 12/31/2022 | Routine policy review. Added clarifying language about line-items reductions under Reimbursement Guidelines. Medical Director approved. (cjw) |
| 4/21/2023 | Added 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) |
| 6/30/2023 | Clarification 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) |
| 8/1/2023 | Respiratory 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) |
| 3/12/2024 | Clarification 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) |
| 11/15/2026 | Anesthesia supplies are considered incidental and are not eligible for separate reimbursement. RPOC approved. Notification on 8/26/2026 for effective date 11/15/2026. (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 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.
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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