Highmark Delaware Reimbursement Policy for Outpatient Services Change

October 2018 ~

Effective November 1, Highmark Delaware will implement changes to its reimbursement policy for outpatient services to better meet current CMS guidelines.

In alignment with the guidelines, outpatient services rendered on the day of an inpatient admission or within three days prior to an inpatient admission will be considered, when applicable, inpatient services and will be included in the inpatient payment.

REIMBURSEMENT POLICY

Applicable services included in this reimbursement policy change, (RP-039) include but are not limited to the following:

• Emergency Department (ED)
• Observation (OBS) and,
• Pre-Admission Testing (PAT)

Highmark DE notes that the above services may also include blood or tissue analysis, radiological testing, cardiac diagnostics, respiratory status testing, etc.

CMS applies a three (3) day rule, also known as the 72‐hour rule, for services provided to outpatients who later are admitted as inpatients. Highmark DE will adhere to this rule as follows for members covered under commercial plans:

• If a member seeks and receives ED services in a facility within a 3-day period prior to an inpatient admission for a related diagnosis then all services shall be billed on the inpatient claim.
• If a member receives Observation services in a facility within a 3-day period prior to an inpatient admission for a related diagnosis then all services shall be billed on the inpatient claim.
• If a member receives pre-admission testing or other outpatient services in a facility within a 3-day period prior to an inpatient admission for a related diagnosis then all services shall be billed on the inpatient claim.

Note: According to CMS, if non‐diagnostic outpatient services are related to the inpatient admission, the services are considered inpatient services and are not separately reimbursable.

EXCLUDED SERVICES

Certain exclusions apply when outpatient services are performed within the designated three day timeframe prior to an inpatient admission. The following services are not to be included on the inpatient claim and must be independently billed:

• Chemotherapy and/or Outpatient Surgery These services should not be included on the inpatient claim as long as they are not performed on the same day of the inpatient admission. If they are performed on the same day as the inpatient admission, then they must be included on the inpatient claim.
• Maternity Services Outpatient diagnostic and/or ED services provided in conjunction with a maternity related diagnosis prior to the inpatient admission should not be included on the inpatient claim.

PROFESSIONAL PROVIDERS (837P and 1500 Billers)

• Inpatient Preoperative Care Reimbursement may be permitted for unusual preoperative medical care or for medical treatment attempted to avoid an operation, even though surgery eventually may be necessary. Highmark Delaware reserves the right to determine what medical care is acceptable to be reimbursed in these situations except when the provider agreement states otherwise.

Source(s): Highmark Delaware Special Bulletins & Mailings;