Effective Date: November 22, 2020
Last Updated: January 17, 2022

Purpose:
To provide reimbursement guidelines for outpatient services related to an inpatient admission or same-day surgery.

Scope:
Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)

Policy:
All outpatient services prior to an admission or same-day surgery that are (1) related to the member’s inpatient stay and (2) performed on the date of admission or same-day surgery, or within three calendar days prior to the date of admission or same-day surgery, are included in the facility’s reimbursement for the inpatient stay and will not be considered for separate reimbursement.  For example, if a member is admitted as an inpatient on a Wednesday, any related outpatient services prior to the admission performed on that Wednesday, or on the preceding Tuesday, Monday, or Sunday, will not be separately reimbursed because reimbursement for such services is included in the reimbursement for the inpatient admission.

Outpatient services prior to an admission or same-day surgery include, but are not limited to, the following:

• Outpatient diagnostic services,
• Pre-admission testing,
• Admission-related outpatient non-diagnostic services,
• Observation services,
• Emergency room services, and
• COVID-19 testing for all inpatient admissions and same-day surgery services.

If the non-diagnostic outpatient services rendered are not related to the inpatient admission or same-day surgery, the facility must report condition code 51 (attestation of unrelated outpatient non-diagnostic services) on the outpatient claim in order for such services to be separately reimbursable.

The following outpatient services prior to an admission or same-day surgery are excluded from this policy and will be reimbursed separately from the inpatient admission or same-day surgery, despite being related to the member’s inpatient stay and performed within three calendar days prior to the date of admission or same-day surgery:

• Outpatient services prior to an admission or same-day surgery rendered at a psychiatric facility or unit more than one calendar day prior to the inpatient admission or same-day surgery;
• Outpatient maternity services prior to an admission or same-day surgery related to a pregnancy; and
• Outpatient services prior to an admission rendered to a member who chooses to be discharged against medical advice.

Procedure:
Horizon NJ Health will not consider for reimbursement any outpatient services prior to an admission or same-day surgery performed on the date of an inpatient admission or same-day surgery, or within three calendar days prior to the date of an admission or same-day surgery, when such outpatient services are related to the inpatient admission or same-day surgery and are submitted by an admitting facility or entity that is associated or affiliated with the admitting facility (e.g., part of hospital system, affiliated ambulatory surgery center, etc,).

Horizon NJ Health will consider for reimbursement any non-diagnostic outpatient services prior to an admission or same-day surgery performed on the date of an inpatient admission or same-day surgery, or within three calendar days prior to the date of admission or same-day surgery, when such outpatient services are (1) not related to the inpatient admission or same-day surgery and (2) billed using condition code 51.

Horizon NJ Health will consider for reimbursement any non-diagnostic outpatient services prior to an admission or same-day surgery that are rendered at a psychiatric facility or unit more than one calendar day prior to an inpatient admission or same-day surgery and are submitted under the designated psychiatric facility or unit’s NPI number.

Horizon NJ Health will consider for reimbursement any non-diagnostic outpatient services prior to a pregnancy-related admission or same-day surgery and submitted with claim condition code B3.

Horizon NJ Health will consider for reimbursement any non-diagnostic outpatient services prior to an admission rendered to a member who chooses to be discharged against medical advice and submitted with discharge code 07.

Horizon reserves the right to review medical documentation when determining the proper application of this policy to a submitted claim.

References:
Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c03.pdf

Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, 90.7
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

CMS MLN Matters Number SE20024, December 3, 2020 “FAQs on the 3 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted as Inpatients”
https://www.cms.gov/files/document/se20024.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services.

Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.