Facility Reimbursement Information

A claim review conducted on an itemized statement involves an examination of that statement and the associated medical records for unbundling of charges and/or inappropriate charges, whether the patient’s status is outpatient or inpatient.

Routine services are those included by the provider in a daily service charge. Routine services are composed of two broad components: (1) general routine service, and (2) special care units (SCU), including coronary care units (CCU) and intensive care units (ICU). Included in routine services are the regular room, dietary services, nursing services, minor medical and surgical supplies, medical social services, psychiatric social services and the use of certain equipment and facilities for which a separate charge is not applicable. 

Equipment commonly available to patients in a setting or ordinarily furnished to patients during a procedure, even though the equipment is rented by the hospital, is considered routine and not billed separately. SCU must be equipped or have available for immediate use, life-saving equipment necessary to treat critically ill patients. The equipment necessary to treat critically ill patients may include, but is not limited to:

• Respiratory and cardiac monitoring equipment 
• Respirators   
• Cardiac defibrillators   
• Wall or canister oxygen and compressed air 

Routine services and supplies are included by the provider in the general cost of the room where services are being rendered or the reimbursement for the associated surgery or other procedures or services. A separate payment is never made for routine bundled services and supplies and, therefore, cannot be billed separately. These are considered floor stock and are generally available to all patients receiving services. Examples include drapes and reusable items. As such, these items should not be billed separately.     

The following guidelines may assist hospital personnel in identifying items, supplies and services that are not separately billable. This is not an all-inclusive list.   

• Any supplies, items and services necessary or otherwise integral to the provision of a specific service and/or the delivery of services in a specific location are considered routine and not separately billable in the inpatient and outpatient environments.  
• All items and supplies, including DME, that may be purchased over the counter are not separately billable, excluding medications.  
• All reusable items, supplies and equipment provided to all patients during an inpatient or outpatient admission.  
• All reusable items, supplies and equipment, such as pulse oximeters, blood pressure cuffs, bedside tables, etc., provided to all patients in a given inpatient/outpatient treatment area or unit.  
• All reusable items, supplies and equipment provided to all patients receiving the same service.

Routine supplies - The hospital’s basic room and critical care area room (cardiac, medical, surgical, pediatric, respiratory, burn, neonate (level III and IV), neurological, rehabilitative, post-anesthesia or recovery and trauma) daily charge shall include all the following services, personal care and supply items and equipment:

The list below provides examples of routine items and services that should be inclusive. Please note that the list is not all-inclusive.

Routine Supplies

Medical equipment - The hospital’s daily charge for basic and critical care area rooms (cardiac, medical, surgical, pediatric, respiratory, burn, neonate (level III and IV), neurological, rehabilitative, post- anesthesia or recovery and trauma) shall include all the following services, personal care and supply items and equipment.   

The allowed amount for daily charges for equipment usage, such as oxygen, ventilator or CPAP, will be prorated based on the total number of hours the equipment and/or supply was in use.

The list of medical equipment below provides examples of items that should be inclusive. Please note that the list is not all-inclusive.

Medical Equipment

Facility basic charges - The hospital’s daily charge for basic and critical care area rooms (cardiac, surgical, pediatric, respiratory, burn, neonate (level III and IV), neurological, rehabilitative, post-anesthesia or recovery and trauma) shall include all the following services, personal care and supply items and equipment. The list of medical equipment below provides examples of items that should be inclusive. Please note that the list is not all-inclusive.

Facility Basic Charges

Ancillary personnel providing nursing or technical services - The list below provides examples of items and services that should be inclusive. Please note that the list is not all-inclusive.

Ancillary Personnel Providing Nursing or Technical Services

Critical care units - The list below provides examples of items and services that should be inclusive. Please note that the list is not all-inclusive.

Critical Care Units

Inpatient and outpatient surgical rooms and services - Includes surgical suites (major and minor), treatment rooms, endoscopy labs, cardiac cath labs, X-ray, pulmonary and cardiology procedural rooms. The hospital’s charge for surgical suites and services shall include the entire above-listed nursing personnel services, supplies and equipment (as included in the basic or critical care daily room charges). 

In addition, the following services and equipment will be included in the surgical rooms and service charges. Please note this list is not all inclusive. Please refer to any state specific guidelines. 

Surgical Rooms and Services