Effective July 1, 2023, Blue Cross and Blue Shield of New Mexico (BCBSNM) is implementing a new Clinical Payment and Coding Policy, Outpatient Facility Service(s) Overlapping During an Inpatient Stay CPCP039, in accordance with guidance from the Centers for Medicare & Medicaid Services (CMS). This new BCBSNM policy applies to claims that are submitted with outpatient service dates that fall entirely within or overlap the timeframe of an inpatient admission.
Under this new BCBSNM policy:
- 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.
- Qualified Healthcare Professional (QHP) services billed on a professional claim while the member is admitted as an inpatient, using an inpatient place of service code, may be eligible for separate reimbursement.
What do I need to do?
Review in detail the new Clinical Payment and Coding Policy — Outpatient Facility Service(s) Overlapping During an Inpatient Stay CPCP039 .