Effective August 1, 2023, Blue Cross and Blue Shield of Texas (BCBSTX) is implementing a new Clinical Payment and Coding Policy CPCP038 Outpatient Services Prior to an Inpatient Admission in accordance with guidance from the Centers for Medicare & Medicaid Services (CMS). BCBSTX will apply a three-day rule for Pre-Admission Testing (PAT) for certain services provided to outpatients who are admitted as inpatients within three days.
We will review claims falling under the three-day payment window. The policy recommends that certain PAT services rendered within three days prior to being admitted to a hospital or facility (or otherwise as noted in the provider contract) are considered ancillary to the inpatient services, included in the inpatient reimbursement and not separately reimbursable.
What should I expect?
Outpatient PAT services falling under the three-day payment window may be included in the inpatient reimbursement if we determine it was performed three days prior to being admitted to a facility.
What do I need to do?
Providers should review their contract and supporting documentation including CPCP038 Outpatient Services Prior to an Inpatient Admission regarding preoperative/preadmission testing for scheduled admissions/surgeries to determine their obligations. Note, provider contracts and supporting documentation supersede this policy.
Be sure to check eligibility and benefits before rendering service(s) to make sure a procedure is a covered benefit for the member and determine any prior authorization requirements.
If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.
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.