What’s changing?
Effective June 1, 2023 Blue Cross and Blue Shield of New Mexico (BCBSNM) is implementing a new Clinical Payment and Coding Policy — Outpatient Services Prior to an Inpatient Admission CPCP038 in accordance with guidance from the Centers for Medicare & Medicaid Services (CMS). We will apply a three-day rule for certain services provided to members who are outpatients who are then later admitted as inpatients.
BCBSNM will review claims that fall under the three-day payment window. The policy states that outpatient related diagnostic or related non-diagnostic services that are rendered within three days prior to being admitted to a hospital or facility are considered inpatient services and are included in the inpatient reimbursement.
The details
Under this new BCBSNM policy:
- If an admitting hospital renders related diagnostic or related non-diagnostic services three days preceding and including the date of a member’s inpatient admission, the services are considered inpatient services and are included in the inpatient reimbursement; or
- If an admitting hospital renders unrelated diagnostic or unrelated non-diagnostic outpatient services three days preceding, including the date of a member’s inpatient admission, the hospital may be reimbursed separately for the unrelated outpatient services.
What should I expect?
We will review claims that fall under the three-day payment window and may include outpatient services in the inpatient reimbursement if we determine a provider has performed services three days prior to being admitted to a facility.
What do I need to do?
Providers should review in detail this new Clinical Payment and Coding Policy, Outpatient Services Prior to an Inpatient Admission — CPCP038.