05/22/2023
Effective September 1, 2023, Blue Cross and Blue Shield of Texas (BCBSTX) is implementing, in accordance with guidance from the Centers for Medicare & Medicaid Services (CMS), a new Clinical Payment and Coding Policy, CPCP039 Outpatient Facility Service(s) Overlapping During an Inpatient Stay. This new BCBSTX policy applies to claims that are submitted with outpatient service dates that fall entirely within or overlap the timeframe of an inpatient admission.
Summary CPCP039
- Unless otherwise specified in provider contracts/plan documents, outpatient service dates that fall completely within inpatient admission and discharge dates, by the same or another facility, or an outpatient bill that overlaps an inpatient admission (unless excluded), are not eligible for separate reimbursement.
- A facility cannot separately bill for outpatient services that were rendered while the member was inpatient.
What do I need to do?
BCBSTX encourages you to read and understand the entire new CPCP039 Outpatient Facility Service(s) Overlapping During an Inpatient Stay located on the Clinical Payment and Coding Policy page on the provider website
If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.
Be sure to check eligibility and benefits before rendering service(s) to make sure a procedure is a covered benefit for the member.
Clinical payment and coding policies are based on using healthcare professionals and industry standard guidelines. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.