Policy Statement
The Plan considers certain hospital services to be integral components of an inpatient admission, and thus, considers such to be included as part of room and board reimbursement. Services, supplies, equipment, and ancillary support activities that fall within this category—as further described in this policy—are not separately reimbursable. The Plan determines the services that are not separately reimbursable in accordance with this policy based on CMS guidance and industry-standard billing practice.
Our health plan considers components of room and board charges as not separately reimbursable. Facilities will not be reimbursed nor allowed to retain reimbursement for services considered to be not separately reimbursable. Pre-admission services, including Emergency Department charges, must be included on the inpatient claim and are subject to guidelines within this policy.
The following are general categories and lists of examples of inpatient facility charges that are not separately reimbursable including, but not limited to:
Central Supply, Floor Stock, and Routine Supplies:
- IV fluids used for hydration and/or to keep lines open (TKO)
- Minor medical and surgical supplies such as culture kits, alcohol wipes, cotton balls, thermometers, gloves, IV flushes (saline and heparin), suture/ staple removal kits, suction kits and canisters, tubing (IV, tube feeding/flush, oxygen) and supplies
- Nutritional supplements to include, but not limited to, tube feeding formulas and protein shakes/powders
- Over the counter (OTC) medications
- Oxygen
- Personal hygiene and/or over the counter supplies such as bedpans, patient gowns, sitz baths, floor supplied breast pump, diapers, cleaning wipes, lip balm, toothpaste
- Supplies and medications provided by the patient
Nursing Care and Treatments
Services provided that are within the scope of normal nursing practice.
Administration of respiratory treatments or services
- Bronchial hygiene therapy (e.g., deep breathing, coughing exercises, intermittent positive pressure breathing (IPPB), postural drainage, chest percussion/vibration and other chest physiotherapy treatments, and nasotracheal/endotracheal suctioning).
- CPAP, BiPap, or ventilator management
- Incentive spirometry
- Nebulizer treatment
- Trach care/changes
- Ventilator management, adjustments, circuit changes, weaning
- Assessments/ monitoring of patients
- Assisting with bedside procedures (e.g., intubation, chest tube placement)
- Blood Administration (transfusions)
- Completing bedside procedures (e.g. IV insertion including any lidocaine used, nasogastric tube placement, urinary catheter placement)
- Dressing changes
- Incremental nursing care
- Pre-op holding for inpatient surgery
- Specimen collection (e.g. catheterization, nasal swab)
- Surgical prep for procedures
- Tube feeding and total parenteral nutrition (TPN) administration
Other Services
- Blood draws by any route, regardless of practitioner performing the draw
- Dietary services
- Medication administration by any route
- Milk bank storage fees
- Point of care testing:
- Glucometry testing (finger stick)
- Mobile computer devices (e.g. epoc® Blood Analysis System, iSTAT, TEG® Hemostatsis Analyzer, Avoximeter, Masimo Rad, bladder scanner) used for the analysis of:
- Blood gases
- Cardiac markers
- Whole blood hemostasis
- Chemistries
- Pulse oximetry
- Co-oximetry
- Urinary retention
Operating Room, Specialty and Intensive Care Units
Regence considers the following to be special life-saving equipment and services that are integral to the care provided on these units/rooms and are not separately reimbursable.
- Post Operative Cardiac Rehab services.
- Equipment use and monitoring that are a required component of a specific level of care
- Arterial Swan-Ganz monitor(ing) in CCU, ICU, NICU, OR, and recovery room
- Cardiac monitor(ing) in burn care, CCU, ICU, NICU, pulmonary care, step-down, operating room, recovery room, telemetry and trauma
- CO2 End Tidal monitor(ing) in the operating room and when on a ventilator.
- Extracorporeal membrane oxygenation (ECMO) equipment, supplies and monitoring in the operating room.
- Fetal monitor(ing) in a labor room setting
- Transesophageal Echo (TEE) monitor(ing) during Open Heart Surgery
- Ventilator use and management in burn care, CCU, ICU, NICU, pulmonary care, and trauma, regardless of the practitioner
- Cleaning of internal or external components of ventilator
- Ventilator adjustments
- Ventilator circuit change
- Ventilator maintenance and calibration
- Ventilator system set up, changes, or checks
- Ventilator weaning and extubation
- Respiratory services provided in burn care, CCU, ICU, NICU, pulmonary care, step-down, operating room, and/or trauma regardless of practitioner performing the services
- Application techniques to support oxygenation and ventilation in an acute illness (e.g., establish/maintain artificial airway, ventilatory therapy, precise delivery of oxygen concentrations, and aid in removal of secretions from pulmonary tree).
- Bronchial hygiene therapy (e.g., deep breathing, coughing exercises, intermittent positive pressure breathing (IPPB), postural drainage, chest percussion/vibration and other chest physiotherapy treatments, and nasotracheal/endotracheal suctioning).
- Continuous or intermittent oximetry monitoring/trending
- Endotracheal suctioning
- Evaluation and assessment for changes in the patient’s condition, particularly in situations where the patient’s respiratory status is unstable and may change suddenly and unpredictably and require medical treatment.
- Patient transport
- Periodic assessment of the patient for the effectiveness of respiratory therapy services when not performed during a treatment session.
- Respiratory assessment when performed during treatment sessions
- Respiratory therapy consultations for instruction on the use of equipment, such as incentive spirometers, or other such breathing apparatuses or techniques.
- Therapeutic use/monitoring of medicinal gases, pharmacologically active mists and aerosols, and equipment (e.g., resuscitators, ventilators).
- Tracheostomy, tracheostomy tube and/or trach collar care
- Transcutaneous monitoring system setup and/or monitoring
Our health plan will limit reimbursement of administration of intermittent inhaled medications to five charges, per date of service, performed by respiratory therapists
References
Cross References
- Adm 125 – Implants, Implant Components, Medical and Surgical Supplies for all Surgical Procedures
- Fac 109 – Reimbursement of IV Solutions, Premixed IV Medications, Intrathecal Solutions and TPN for Facilities
- Fac 110 – Emergency Department Visits: Level of Service
- Fac 111 – Facility DRG Validation
- Med 108 – Discarded Drugs and Biologicals
