Itemized Bill Review (IBR) Program

Introduction

We are publishing this clarification based on the increase in questions recently received regarding the Itemized Bill Review (IBR) program conducted by our vendor-partner, CERiS.*

This section includes guidelines on reimbursement to providers and facilities for services on claims paid by a diagnosis-related group (DRG) with an outlier paid at percent of billed charge or where the entire claim is paid at percent of billed charge. Our vendor-partner or our internal team may review these claims as part of our IBR program to ensure appropriate reimbursement. Documentation, including a summary of adjusted charges, will be provided for each claim upon completion of the review.

Disputes related to the review may be submitted according to the instructions in the documentation received upon completion of the review.

In addition to any header in this section, please refer to all other service specific sections that may have more stringent guidelines. There may be multiple sections that apply to any given reimbursable service.

Audits/reviews/records requests

At any time, a request may be made for on-site, electronic, or hard copy medical records, utilization review documentation and/or itemized bills related to claims for the purposes of conducting audits or reviews.

Blood and blood products

Administration of blood or blood products are not separately reimbursable on inpatient (IP) claims. Administration charges on outpatient (OP) claims are separately reimbursable when submitted without observation/treatment room charges.

Charges for blood storage and processing, thawing fees charges, irradiation, and other processing charges are also not separately reimbursable.

Emergency room supplies and services charges

The emergency room level reimbursement includes all monitoring, equipment, supplies, and time and staff charges. Reimbursement for the use of the emergency room includes the use of the room and personnel employed for the examination and treatment of patients. This reimbursement does not typically include the cost of physician services.

Facility personnel charges

Charges for IP services for facility personnel are not separately reimbursable and the reimbursement for such is included in the room and board rate. Examples include, but are not limited to, lactation consultants, dietary consultants, overtime charges, transport fees, nursing functions (including intravenous IV or peripherally inserted central catheter PICC line insertion at bedside), professional therapy functions, including physical, occupational, and speech call back charges, nursing increments, therapy increments, and bedside respiratory and pulmonary function services. Charges for OP services for facility personnel are also not separately reimbursable. The reimbursement is included in the payment for the procedure or observation charge.

Implants

Implants are objects or materials that are implanted such as a piece of tissue, a tooth, a pellet of medicine, a medical device, a tube, a graft, or an insert placed into a surgically or naturally formed cavity of the human body to continuously assist, restore, or replace the function of an organ system or structure of the human body throughout its useful life. Implants include, but are not limited to stents, artificial joints, shunts, pins, plates, screws, anchors, and radioactive seeds, in addition to non-soluble, or solid plastic materials used to augment tissues or to fill in areas traumatically or surgically removed. Instruments that are designed to be removed or discarded during the same operative session during which they are placed in the body are not implants. In addition to meeting the above criteria, implants must also remain in the member's body upon discharge from the IP stay or OP procedure.

Staples, sutures, clips, as well as temporary drains, tubes, similar temporary medical devices, and supplies shall not be considered implants. Implants that are deemed contaminated and/or considered waste and/or were not implanted in the member will not be reimbursed.

IV sedation and local anesthesia

Charges for IV sedation and local anesthesia administered by the provider performing the procedure, and/or nursing personnel, are not separately reimbursable and are included as part of the operating room (OR) time/procedure reimbursement. Medications used for IV sedation and local anesthesia are separately reimbursable.

Lab charges

The reimbursement of charges for specimen collection are considered facility personnel charges and the reimbursement is included in the room and board or procedure/observation charges. Examples include venipuncture, urine/sputum specimen collection, draw fees, phlebotomy, heel sticks, and central line draws.

Processing fees, handling fees, and referral fees are considered included in the procedure/lab test performed and not separately reimbursable.

Labor care charges

Reimbursement will be made for appropriately billed room and board or labor charges. Payment will not be made on both charges when billed concurrently.

Nursing procedures

Fees associated with nursing procedures or services provided by facility nursing staff or unlicensed facility personnel (technicians) performed during an IP admission or OP visit will not be reimbursed separately. Examples include, but are not limited, to IV injections or IV fluid administration/monitoring, intramuscular injections, subcutaneous injections, IV or PICC line insertion at bedside, nasogastric tube insertion, urinary catheter insertion, point of care/bedside testing (such as glucose, blood count, arterial blood gas, clotting time, etc.) and IP blood transfusion administration/monitoring (with the exception of OP blood administration or OP chemotherapy administration which are submitted without observation/treatment room charges).

OR time and procedure charges

The OR charge will be based on a time or procedural basis. When time is the basis for the charge, it should be calculated from the time the patient enters the room until the patient leaves the room, as documented on the OR nurse’s notes. The operating room charge will reflect the cost of:

• The use of the operating room.
• The services of qualified professional and technical personnel.

Personal care items and services

Personal care items used for patient convenience are not separately reimbursable. Examples include but are not limited to breast pumps, deodorant, dry bath, dry shampoo, lotion, non-medical personnel, mouthwash, powder, soap, telephone calls, television, tissues, toothbrush and toothpaste, bedpans, chux, hot water bottles, icepacks, pillows, sitz baths, and urinals.

Pharmacy charges

Reimbursement will be made for the cost of drugs prescribed by the attending physician. Additional separate charges for the administration of drugs, the cost of materials necessary for the preparation and administration of drugs, and the services rendered by registered pharmacists and other pharmacy personnel will not be reimbursed separately. All other services are included in the drug reimbursement rate. Example of pharmacy charges which are not separately reimbursable include, but are not limited toIV mixture fees, IV diluents such as saline and sterile water, IV piggyback, Heparin and saline flushes to administer IV drugs, and facility staff checking the pharmacy cart.

Portable charges

Portable charges are included in the reimbursement for the procedure, test, or x-ray, and are not separately reimbursable.

Pre-operative care or holding room charges

Charges for a pre-operative care or a holding room used prior to a procedure are included in the reimbursement for the procedure and are not separately reimbursed. In addition, nursing care provided in the pre-operative care areas will not be reimbursed separately.

Preparation (set-up) charges

Charges for set-up, equipment, or materials in preparation for procedures or tests are included in the reimbursement for that procedure or test.

Recovery room charges

Reimbursement for recovery room services (time or flat fee) includes the use of all and/or available services, equipment, monitoring, and nursing care that is necessary for the patient’s welfare and safety during their confinement. This will include but is not limited to cardiac/vital signs monitoring, pulse oximeter, medication administration fees, nursing services, equipment, supplies, (whether disposable or reusable), defibrillator, and oxygen. Separate reimbursement for these services will not be made.

Recovery room services related to IV sedation and/or local anesthesia

Separate reimbursement will not be made for a phase I or primary recovery room charged in connection with IV sedation or local anesthesia. Charges will be paid only if billed as a post procedure room or a phase II recovery (step-down). Examples of procedures include arteriograms and cardiac catheterization.

Supplies and services

Items used for the patient that are needed as a direct result of a procedure or test are considered part of the room and board or procedure charges and are not separately reimbursable.

Any supplies, items, and services that are necessary or otherwise integral to the provision of a specific service and/or the delivery of services in a specific location are considered routine services and not separately reimbursable in the IP and OP environments.

Special procedure room charge

Special procedure room charges are included in the reimbursement for the procedure.If the procedure takes place outside of the OR suite, then OR time will not be reimbursed to cover OR personnel/staff being present in the room. Example: ICU, GI lab, etc.

Stand-by charges

Standby equipment and consumable items that are on standby are not reimbursable. Standby charges for facility personnel are included in the reimbursement for the procedure and not separately reimbursable.

Stat charges

Stat charges are included in the reimbursement for the procedure, test, and/or x-ray. These charges are not separately reimbursable.

Supplies and equipment

Charges for medical equipment, including but not limited to, IV pumps, patient-controlled analgesia (PCA) pumps, oxygen, and isolation carts and supplies are not separately reimbursable.

Telemetry

Telemetry charges in ER/ ICU/CCU/NICU or telemetry unit (step-down units) are included in the reimbursement for the place of service. Additional monitoring charges are not reimbursable.

Time calculation:

• OR — Time should be calculated on the time the patient enters the room until the patient leaves the room, as documented on the OR nurse’s notes.
• Hospital/technical anesthesia—Reimbursement of technical anesthesia time will be based on the time the patient enters the OR until the patient leaves the room as documented on the OR nurse’s notes. The time the anesthesiologist spends with the patient in pre-op and the recovery room will not be reimbursed as part of the hospital anesthesia time.
• Recovery room — The reimbursement of recovery room charges will be based on the time the patient enters the recovery room until the patient leaves the recovery room as documented on the post anesthesia care unit (PACU) record.

• Post recovery room — Reimbursement will be based on the time the patient leaves the recovery room until discharge.

Video or digital equipment used in OR

Charges for video or digital equipment used in a surgery are included in the reimbursement for the procedure and are not separately reimbursable. Charges for batteries, covers, film, anti-fogger solution, tapes, etc. are not separately reimbursable.

Additional reimbursement guidelines for disallowed charges

The disallowed charges (charges not eligible for reimbursement) include, but are not limited to, the following, whether billed under the specified revenue code or any other revenue code. These guidelines may be superseded by your specific agreement. Refer to your contractual fee schedule for payment determination.

The tables below illustrate examples of non-reimbursable items/services codes.