Payment Policy: Inpatient Only Procedure (Ambetter Only)

Payment Policy: Inpatient Only Procedure (Ambetter Only)

Reference Number: MP.PP.018

Product Types: Ambetter

Effective Date: 01/01/2013

Coding Implications

Last Review Date: 12/01/2022

Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Policy Overview The Centers for Medicare and Medicaid Services (CMS) has determined that certain procedures should only be performed in an inpatient setting and therefore, are not appropriate to be conducted in an outpatient facility setting. According to CMS,

"Inpatient only services are generally, but not always, surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged."

Inpatient only procedures (IOP) are not payable under the Outpatient Prospective Payment System (OPPS). CMS designates IOP with an OPPS status indicator of "C" in the OPPS Addendum B. The published list can be viewed here:

Application This policy applies to Ambetter.

Claims Reimbursement Edit Code auditing software denies procedures that CMS determines should be performed in an inpatient only setting when billed in the outpatient setting.

State-specific rules, health plan contracts or health plan policies, may supersede this edit.

Rationale for Edit Because of the invasive nature of certain procedures, the need for at least 24 hours of postoperative recovery time or monitoring before a patient can be safely discharged, or the underlying physical condition of the patient requiring surgery, CMS has determined that certain procedures are safest when performed in an inpatient setting.

Coding and Modifier Information This payment policy references Current Procedural Terminology (CPT?). CPT? is a registered trademark of the American Medical Association. All CPT? codes and descriptions are copyrighted 2022, American Medical Association. All rights reserved. CPT codes and CPT descriptions are included for informational purposes only. Codes referenced in this payment policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

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PAYMENT POLICY

INPATIENT ONLY PROCEDURES (AMBETTER)

The following codes are not subject to this policy and are reimbursed in outpatient settings for Ambetter health plans only:

CPT/HCPCS Code

22855 00192 00670 00846 00944 01214 11005 15757 19260 19307 19361 21343 21365 21422 21620 21899 22600 22630 22633 22818 22846 22852 22855 22856 23472 23472 24999 26989 27036 27075 27130 27130 27134 27170 27222 27447 27447 27470

Descriptor

Remove spine fixation device Anesth facial bone surgery Anesth spine cord surgery Anesth hysterectomy Anesth vaginal hysterectomy Anesth hip arthroplasty Debride abdom wall Free skin flap microvasc Removal of chest wall lesion Mast mod rad Breast reconstr w/lat flap Open tx dprsd front sinus fx Opn tx complx malar fx Treat mouth roof fracture Partial removal of sternum - Could be wound closure, Soft tissue, Debridement only Neck/chest surgery procedure Neck spine fusion Lumbar spine fusion Lumbar spine fusion combined Kyphectomy 1-2 segments Insert spine fixation device Remove spine fixation device Remove spine fixation device Cerv artific diskectomy Reconstruct shoulder joint Reconstruct shoulder joint Upper arm/elbow surgery Hand/finger surgery Excision of hip joint/muscle Resect hip tumor Total hip arthroplasty Total hip arthroplasty Revise hip joint replacement Repair/graft femur head/neck Treat hip socket fracture Total knee arthroplasty Total knee arthroplasty Repair of thigh

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PAYMENT POLICY

INPATIENT ONLY PROCEDURES (AMBETTER)

CPT/HCPCS Code

27472 27486 27514 27535 27535 27536 27599 27703 27724 29999 29999 30999 33477 33967 35301 37182 37215 37618 37799 38724 39220 42426 43279 43282 43283 43774 44005 44055 44110 44188 44204 44602 44602 44799 44800 44960 44970 45400 46999 47100 47120 47379

Descriptor

Repair/graft of thigh Revise/replace knee joint Treatment of thigh fracture Treat knee fracture Treat knee fracture Treat knee fracture Leg surgery procedure Reconstruction ankle joint Repair/graft of tibia Arthroscopy of joint Arthroscopy of joint Nasal surgery procedure Implant tcat pulm vlv perq Insert i-aort percut device Rechanneling of artery Insert hepatic shunt (tips) Transcath stent cca w/eps Ligation of extremity artery Vascular surgery procedure Removal of lymph nodes neck Resect mediastinal tumor Excise parotid gland/lesion Lap myotomy heller Lap paraesoph her rpr w/mesh Lap esoph lengthening Lap rmvl gastr adj all parts Freeing of bowel adhesion Correct malrotation of bowel Excise intestine lesion(s) Lap colostomy Laparo partial colectomy Suture small intestine Suture small intestine Unlisted px small intestine Excision of bowel pouch Appendectomy Laparoscopy appendectomy Laparoscopic proc Anus surgery procedure Wedge biopsy of liver Partial removal of liver Laparoscope procedure liver

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PAYMENT POLICY

INPATIENT ONLY PROCEDURES (AMBETTER)

CPT/HCPCS Code

47380 47600 48510 49203 49203 49204 49255 49329 49659 50040 50060 50405 50545 51840 51900 53415 54430 55866 57280 57308 58140 58150 58150 58180 58267 58548 58700 58720 58740 58750 58952 59120 60271 60505 60650 61500 61624 62223 63048 63057 63081 63082

Descriptor

Open ablate liver tumor rf Removal of gallbladder Drain pancreatic pseudocyst Exc abd tum 5 cm or less Exc abd tum 5 cm or less Exc abd tum over 5 cm Removal of omentum Laparo proc abdm/per/oment Laparo proc hernia repair Drainage of kidney Removal of kidney stone Revision of kidney/ureter Laparo radical nephrectomy Attach bladder/urethra Repair bladder/vagina lesion Reconstruction of urethra Revision of penis Laparo radical prostatectomy Suspension of vagina Fistula repair transperine Myomectomy abdom method Total hysterectomy Total hysterectomy Partial hysterectomy Vag hyst w/urinary repair Lap radical hyst Removal of fallopian tube Removal of ovary/tube(s) Adhesiolysis tube ovary Repair oviduct Resect ovarian malignancy Treat ectopic pregnancy Removal of thyroid Explore parathyroid glands Laparoscopy adrenalectomy Removal of skull lesion Transcath occlusion cns Establish brain cavity shunt Remove spinal lamina add-on Decompress spine cord add-on Remove vert body dcmprn crvl Remove vertebral body add-on

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PAYMENT POLICY

INPATIENT ONLY PROCEDURES (AMBETTER)

CPT/HCPCS Code

63267 63267 63707 63709 63709 64760 64911 64999 66999 75952 G0341 G0343

Descriptor

Excise intrspinl lesion lmbr Excise intrspinl lesion lmbr Repair spinal fluid leakage Repair spinal fluid leakage Repair spinal fluid leakage Incision of vagus nerve Neurorraphy w/vein autograft Nervous system surgery Eye surgery procedure Endovasc repair abdom aorta Percutaneous islet celltrans Laparotomy islet cell transp

References 1. Current Procedural Terminology (CPT?), 2022 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services 3. Centers for Medicare and Medicaid Services, Hospital Outpatient PPS

Revision History 03/14/2017

5/31/2017 11/01/2019 11/01/2020 11/30/2021 12/01/2022

Created Ambetter specific version of policy which excludes a list of codes. Corrected formatting and revised code list. Annual Review completed. Annual Review completed Annual Review completed; no major updates required Annual Review completed; no major updates required

Important Reminder For the purposes of this payment policy, "Health Plan" means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plan's affiliates, as applicable.

The purpose of this payment policy is to provide a guide to payment, which is a component of the guidelines used to assist in making coverage and payment determinations and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage and payment determinations and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable plan-level administrative policies and procedures.

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