Charges That Are Not Separately Reimbursable
Charges that are customarily and/or intrinsically included in room and board or as part of another service or procedure.
Emergency Department – Hospital facility that is staffed 24 hours a day, 7 days a week, and provides unscheduled outpatient service to patients whose conditions require immediate care.
Inpatient
Per CMS, an inpatient is a person who has been admitted to a hospital or skilled nursing facility for bed occupancy to receive inpatient hospital or skilled nursing services. A person is considered an inpatient if they are formally admitted as an inpatient with the expectation that they will remain at least overnight and occupy a bed even though it later develops that they can be discharged or is transferred to another hospital and does not actually use a hospital bed overnight.
Non-Routine Supplies
Items that are not considered routine (as defined below) and are specific to the patient’s treatment and ordered specifically for the patient by the physician and/or required for a treatment ordered by a physician for a specific plan of care.
- Examples of non-routine supplies include but are not limited to catheters, unusual wound care supplies unique for a specific patient, ostomy supplies.
Room and Board
Defined by the Centers for Medicare & Medicaid Services (CMS) as a daily service charge by hospitals for “inpatient routine services”.
Routine services
Regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made.
Routine services are composed of two “board” components:
- General routine services
- Special care units (SCUs), including coronary care units (CCUs) and Intensive Care Units (ICUs)
- Common routine nursing services include, but are not limited to IV infusions and injections, blood administration, and nebulizer treatments, by a nurse.
- Point of care testing (POCT) is another service routinely performed by non-laboratory trained professional including nurses. These tests allow for quicker results and improve patient outcomes.
- Common routine supplies that are not specific to a patient’s treatment.
Special Care Units/Intensive Care Type Units
Per CMS, the special care unit must be one in which the nursing care required is extraordinary and on a concentrated and continuous basis. Extraordinary care incorporates extensive lifesaving nursing services of the type generally associated with nursing services provided in burn, coronary care, pulmonary care, trauma, and intensive care units. Special life-saving equipment is routinely available in the unit.
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 non-reimbursable. Emergency Department charges must be included on Inpatient claim for same facility 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:
Nursing care and treatment that are within the scope of normal nursing practice are not separately reimbursable, including, but not limited to:
- Assessments/monitoring of patients
- Pre-op holding for inpatient surgery
- Surgical prep for procedures
- IV insertion, including lidocaine
- IV infusions, including nutritional supplements, total parenteral nutrition (TPN), and injections
- Medication administration, including those administered via IV push, IV infusion, IM injections, Sub-Q injections, Intradermal injection.
- Blood Administration (transfusions)
- Administration of respiratory treatments (this does not apply to respiratory treatments provided by respiratory therapists or medications) including, but not limited to:
- Incentive spirometry
- Nebulizer treatments
- Venipuncture, central line draws
- Tube feedings, including formulas and supplements
Point of care testing, including but not limited to:
- Urine dip stick
- Glucometry testing (finger stick)
Mobile computer devices such as, but not limited to, those used for the analysis of:
- Blood gases
- Cardiac markers
- Whole blood hemostasis
- Chemistries
- Pulse oximetry
- Co-oximetry
- Urinary retention
- Examples of mobile computer devices include, but are not limited, to:
epoc Blood Analysis System
iSTAT
Minicare series
TEG Hemostatsis Analyzer Avoximeter Masimo Rad-57 * Bladder scanner
Laboratory services (excluding anatomic pathology services and certain clinical pathology services), including, but not limited to:
- Specimen collection fees where the cost of collecting the specimen is minimal e.g., Routine capillary puncture for glucose or clotting or bleeding time.
Routine/ Central Supply (floor stock) items, including, but not limited to:
- Minor medical and surgical supplies such as culture kits, alcohol wipes, cotton balls, thermometers, gloves, IV flushes (saline and heparin), kits containing routine supplies (suture/ staple removal kits)
- Personal hygiene supplies such as bedpans, patient gowns, sitz baths, floor supplied breast pump, diapers, and wipes
- Routine bundled supplies
- Over-the-counter supplies (lip balm, toothpaste)
- Supplies and medications provided by the patient.
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.