Covered and Noncovered Services : Codes

Procedures Reimbursable Only as Inpatient Hospital Services

Certain surgical procedures listed below will not be reimbursed on an outpatient hospital facility claim. These services will therefore be reimbursed to professional providers only when performed in an inpatient hospital setting. These services are determined by outpatient hospital reimbursement methodology, EAPG.

Outpatient hospital providers billing on a UB-04 Claim Form and physician providers billing these services on professional claims (that is, the 837P transaction or the 1500 Health Insurance Claim Form) are affected by this policy.

The following table lists services that are not reimbursed in an outpatient hospital setting and are based upon EAPG 993, which is developed and assigned by 3M. This list will be periodically updated.

Note: Outpatient hospital claim reimbursement may be impacted by other coding data sets including the National Correct Coding Initiative's Medically Unlikely Edits, which can cause a detail on a claim to deny.

Policy information for CPT and HCPCS procedure codes is subject to change; providers should refer to the interactive maximum allowable fee schedule for the most current list of allowable procedure codes.