Purpose:
The purpose of this policy is to clarify and define the multiple types of admissions and establish specific criteria and adjudication guidelines.

Policy:
Diagnostic Admission:
An inpatient hospital stay or a portion of an inpatient hospital stay that is for the sole purpose of performing x-rays, laboratory tests or other diagnostic tests that could have been performed safely in an outpatient setting.

Benefits for a diagnostic admission is rarely approved for adjudication.  There are some instances, however, when the diagnostic procedure (s) cannot be safely performed or the patient’s clinical status justifies such an admission.  Documentation must be reviewed that indicates the medical necessity for the diagnostic inpatient stay. 

If the entire admission is deemed diagnostic and there have been no exceptions made due to special circumstances, the claim will be adjudicated in the following manner:

• Deny all room and board charges.
• Facility charges for laboratory, x-rays and covered miscellaneous charges will be reimbursed as if they were rendered in an outpatient setting.
• Physician services should be reimbursed as an office visit.

If a portion of the diagnostic admission is considered non-diagnostic in nature and is appropriate for reimbursement, but the rest of the admission is diagnostic, the claim will be adjudicated in the following manner:

• Pay room and board only for those days that are deemed medically appropriate.  All other room and board charges should be denied.
• Pay all facility laboratory, x-ray and covered miscellaneous charges as part of the admission period.
• The physician should be reimbursed for the non-diagnostic portion of the hospitalization with CPT codes that are appropriate for inpatient hospital visits; however, if there is a portion that is considered diagnostic, the physician should be reimbursed for the diagnostic portion of the hospital stay as an office visit(s).

Court Ordered Admissions
There are two (2) types of court ordered (involuntary) admissions.  They are Judicial Admissions and Probate Admissions.

Judicial Admissions are ordered by a judge to determine competency for an individual who is to stand trial.  This type of admission can order an individual to be committed up to 15 days with a 15 day extension if warranted by the presiding judge.  After that time, the individual is returned to court to stand trial or may/may not be committed for treatment.

Blue Cross Blue Shield of South Carolina has no liability for admissions related to competency determinations. However, if the patient is admitted following the admission for the competency determination, psychiatric contract benefits will apply.

Probate Admissions are those admissions, which occur whenever a patient is either unwilling or unable to be voluntarily admitted for necessary treatment, whether for mental illness or substance abuse.  Such admissions are subject to the medical necessity criteria and must meet all contract limitations/exclusions applicable.

If deemed necessary, a judge’s court order may be requested for either type of admission.  Admissions as an alternative to incarceration are not a covered service. 

Week-end Admissions
Services rendered after close of business day on Friday through beginning of business day the following Monday are considered weekend admissions.

If the following criteria are met, no reimbursement penalty should be assessed.

• Pre-approval has been obtained
• There is an acute nature of the admission requiring immediate hospitalization (i.e., heart attack, stroke, chest pain, etc.)

Notification of a weekend admission must be obtained within 24 hours or a precert penalty may be assessed.  Please review specific contract verbiage for exclusion, limitations and/or maximums.