Services Bundled into Inpatient / Outpatient Stays
Origination Date: 06/2021
Last Review Date: 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 bag | Fans | Patient room furniture; manual, electric, semielectric beds |
| Aqua pad motor | Feeding pumps | PCA pump |
| Arterial pressure monitors (inclusive of Critical Care room charges only) | Flow meters | Pen light or other flashlight |
| Auto Syringe Pump | Footboard | PICC line (reusable equipment associated with PICC line placement) |
| Automatic thermometers and blood pressure machines | Glucometers | Pill pulverizer |
| Bed scales | Guest beds | Pressure bags or pressure infusion equipment |
| Bedside commode | Heating or cooling pumps | Radiant warmer |
| Blood pressure cuffs | Hemodynamic monitors (inclusive of Critical Care room charges only) | Sitz bath |
| Blood warmers | Humidifiers | Stethoscope |
| Cardiac monitors | Infant warmer | Suction pumps |
| CO2 monitors | Injections (therapeutic, prophylactic, or diagnostic) | Telephone |
| Crash cart | IV pumps; single and multiple lines, tubing | Televisions |
| Defibrillator and paddles | Nebulizers | Traction equipment |
| Digital recording equipment and printouts | Overhead frames | Transport isolette |
| Dinamap | Over-bed tables | Wall suction, continuous or intermittent |
| Emerson pumps | Oximeter/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 venipuncture | Insert, discontinue, and/or maintain nasogastric tubes | Point-of-Care (POC) Testing (ABG’s, Glucose, Electrolytes, Troponin, etc.) |
| Assisting patient onto bedpan, bedside commode or into bathroom | Intubation | Preoperative care |
| Bathing of patients | Maintenance and flushing of Jtubes, PEG tubes, and feeding tubes of any kind | Respiratory therapy services |
| Bedside Glucose monitoring | Maintenance of oxygen administration equipment | Set 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 cannulas | Medical record documentation | Shampoo hair |
| Body preparation of deceased patients | Mixing, 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 flushes | Start 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 oximetry | Monitoring 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 checks | Transporting, ambulating, range of motion, transfer to and from bed or chair |
| Changing of linens and patient gowns | Nursing care | Turning 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 services | No separate charge will be allowed for callback, emergency, standby, urgent attention, ASAP, STAT, or portable fees. | |
| Feeding of patients | Oral care | |
| Not Separately Reimbursable Routine Supplies | ||
| Admission, hygiene, and or comfort kits | IV (intravenous) arm boards | Saline solutions |
| Alcohol swabs | IV Solutions 500cc or less (used for flushes or to mix medications) | Shampoo |
| Arterial blood gas kits | Lotion | Sharps container |
| Baby powder | Lubricant | Shaving cream |
| Band-aids | Masks (patient or staff) | Skin cleansing liquid |
| Basin | Meal trays | Soap |
| Bedpan, regular or fracture pan | Measuring pitcher | Socks/slippers |
| Blood tubes | Mid-stream urine kits | Specipan |
| Cotton balls (sterile or nonsterile) | Mouth care kits | Sputum trap |
| Deodorant | Mouthwash | Syringes |
| Drapes | Needles | Tape |
| Dressings and bandages | Odor eliminator/ Room deodorizer | Thermometers |
| Emesis basin | Oral swabs | Tissues |
| Flushes (Heparin, Saline, water, etc.) | Oxygen | Toilet paper |
| Gloves (patient or staff) | Oxygen masks | Tongue depressors |
| Glycerin swabs | Pillows | Toothpaste |
| Heat light or heating pad | Preparation kits | Tubing (IV, suction, equipment, etc.) |
| Ice packs | Razors | Urinal |
| Irrigation solutions | Restraints | Water pitcher |
| Items used to obtain a specimen or complete a diagnostic or therapeutic procedure | Reusable sheets, blankets, pillowcases, draw sheets, underpads, washcloths and towels | |
| Not Separately Reimbursable Routine Critical Care Services | |
| Daily Ventilator, CPAP, and/or BiPAP Management | Respiratory 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 Care | Telemetry |
| Not Separately Reimbursable Routine Surgical Services and Supplies | ||
| Air conditioning and filtration | Fracture tables | Robotic surgical systems |
| All reusable instruments charged separately | Grounding pads | Room heating/cooling and monitoring equipment |
| All services rendered by RN’s, LPN’s, scrub technicians, surgical assistants, orderlies, and aides | Hemochron | Room set-ups of equipment and supplies |
| Anesthesia equipment, supplies and monitors | Hemoconcentrator | Saline slush machine |
| Any automated blood pressure equipment | Hemostatic agents (Tisseel, FloSeal, etc) | Skin closure devices (sutures, staples, etc.) |
| Cardiac monitors | Instrument trays | Solution warmer |
| Cardiopulmonary bypass equipment | Laparoscopes, bronchoscopes, endoscopes, and accessories | Surgeons’ loupes or other visual assisting devices |
| CO2 monitors | Lights, light handles, light cords, fiber optic microscopes | Surgical clips and staplers (reloads, etc.) |
| Crash carts | Local Anesthesia (long or short acting) | Surgical drill |
| Digital recording equipment and printouts | Monopolar and bipolar electrosurgical/bovie and cautery (equipment and handpieces) | Transport monitor |
| Dinamap | Negative pressure wound therapy (vacuum assisted closure devices) | Video camera and tape |
| Disposable surgical supplies (trocars, blades, gowns, guide wires, etc.) | Obtaining laboratory specimens | Wall suction equipment |
| Facility service charge for surgical services includes the routine tables for Equipment, Services, and Supplies | Power equipment | X-ray film |
| Flat or Per day supply fees | Reusable surgical equipment, instruments and trays | |
| Not Separately Reimbursable Respiratory Services | ||
| Bedside pulmonary mechanics | Intubation assistance | Sleep apnea monitoring system (setup, screening and monitoring) |
| Chest manipulation (external chest wall oscillation) | Mini bronchoalveolar lavage test | Spontaneous breathing screen/trial |
| Cleaning of internal or external components of ventilator | Monitoring during transport or for special procedure | Static pressure/volume loop |
| Diaphragmatic EMG sensor catheter placement | Nasal cannula system | Supplemental oxygen (systemsetup, patient/systemassessment, equipment change) |
| End tidal carbon dioxide systemsetup and/or monitoring (expired gas determination) | Oral care | Surfactant administration |
| Equipment change (all noninvasive and invasive) from one type of respiratory assist device to another | Oximetry check and/or trending | Therapeutic ventilatory maneuver (recruitment maneuver) |
| Esophageal balloon catheter placement | Placement or change of in-line suction catheter | Tracheostomy tube care |
| Esophageal pressure monitoring | Positive expiratory pressure (PEP) breathing device, instruction and/or therapy | Transcutaneous monitoring (initial system setup and/or monitoring) |
| FRC (functional residual capacity) determination | Respiratory assessment and/or respiratory protocol assessment | Vent-acquired pneumonia prevention activities |
| Gas cylinder change | Respiratory therapy education | Ventilator circuit change |
| Heliox ventilation | Saline diluents | Ventilator 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
| Date | Description |
| 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) |
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.