Notification

Acute Care Facility Inpatient Transfers


Notification Issue Date: 12/02/2019

This policy will become effective 12/30/2019.
The following criterion has been added to this policy as not medically necessary:

  • The transfer is to return the individual back to the originating facility when the facility to which the individual was transferred is capable of addressing the individual’s medical needs.

The following policy criteria have been revised for nonemergency transfers:

Transfer of a registered inpatient from one acute care facility to another acute care facility on a nonemergency basis to obtain necessary specialized therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The necessary therapeutic services are not available at the facility in which the individual is admitted as a registered inpatient;
  • The necessary therapeutic services are available at the facility to which the individual is being transferred.
  • The individual has been accepted for admission at the nearest appropriate facility that is capable of addressing the individual’s medical needs.
The description section of this policy was revised to incorporate a definition for Emergency Transfer.


Medical Policy Bulletin


Title:Acute Care Facility Inpatient Transfers

Policy #:12.04.04a

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

MEDICALLY NECESSARY

EMERGENCY TRANSFERS
Transfer of a registered inpatient from one acute care facility to another acute care facility for inpatient admission on an emergency basis to obtain necessary specialized diagnostic and/or therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • There is a medical condition that is life or limb threatening or the professional provider deems to be life or limb threatening, and the individual's condition is such that a delay in transfer poses a threat to the individual's survival or seriously endangers the individual's health or could result in serious impairment to the individual's bodily functions and/or serious dysfunction of any of the individual's bodily organs or parts;
  • The necessary diagnostic and/or therapeutic services are not available at the facility in which the individual is admitted as a registered inpatient;
  • The necessary diagnostic and/or therapeutic services are available at the facility to which the individual is being transferred.
  • The individual has been accepted for admission at the nearest appropriate facility that is capable of addressing the individual’s medical needs.

NONEMERGENCY TRANSFERS
Transfer of a registered inpatient from one acute care facility to another acute care facility for inpatient admission on a nonemergency basis to obtain necessary specialized therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The necessary therapeutic services are not available at the facility in which the individual is admitted as a registered inpatient;
  • The necessary therapeutic services are available at the facility to which the individual is being transferred.
  • The individual has been accepted for admission at the nearest appropriate facility that is capable of addressing the individual’s medical needs.

NOT MEDICALLY NECESSARY

Transfer of a registered inpatient from one acute care facility to another acute care facility for any other reason is considered not medically necessary and, therefore, not covered. Examples of transfers that are considered not medically necessary include, but are not limited to, the following situations:
  • The requirements in this policy are not met, regardless of the individual's condition.
  • The transfer is for the purpose of obtaining a non-covered service.
  • The transfer is primarily for the convenience of the individual or the individual's family or healthcare professional.
  • The transfer is to return the individual back to the originating facility when the facility to which the individual was transferred is capable of addressing the individual’s medical needs.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, inpatient transfers are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

MANDATES

This policy is in compliance with federal, state, and local mandates.

Description

Inpatient transfers involve the transfer of a registered inpatient from one acute care facility to another acute care facility.

Emergency transfer refers to the transfer of an individual from one acute care facility to another acute care facility due to the presence of a medical condition that is deemed to be life or limb threatening, and where the transferring facility does not have the necessary specialized diagnostic and/or therapeutic services to effectively treat the member.
References

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 3: Inpatient Hospital Billing. 40.2.4: IPPS Transfers Between Hospitals. Part A: Transfers Between IPPS Prospective Payment Acute Care Hospitals; p.116. [CMS Web site]. Available at: http://www.cms.gov/manuals/downloads/clm104c03.pdf. Accessed May 31, 2019.


Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network. Acute Care Hospital Inpatient Prospective Payment. [CMS Web site]. Available at: http://www.cms.gov/MLNProducts/downloads/AcutePaymtSysfctsht.pdf. Accessed May 31, 2019.

Company Benefit Contracts.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements



Policy History

12.04.04a
12/30/2019This policy will become effective 12/30/2019.
The following criterion has been added to this policy as not medically necessary:
  • The transfer is to return the individual back to the originating facility when the facility to which the individual was transferred is capable of addressing the individual’s medical needs.
The following policy criteria have been revised for nonemergency transfers:

Transfer of a registered inpatient from one acute care facility to another acute care facility on a nonemergency basis to obtain necessary specialized therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The necessary therapeutic services are not available at the facility in which the individual is admitted as a registered inpatient;
  • The necessary therapeutic services are available at the facility to which the individual is being transferred.
  • The individual has been accepted for admission at the nearest appropriate facility that is capable of addressing the individual’s medical needs.
The description section of this policy was revised to incorporate a definition for Emergency Transfer.

12.04.04
01/01/2019This policy will become effective 01/01/2019.

This new policy has been developed to communicate the Company’s coverage criteria for Acute Care Facility Inpatient Transfers.

Version Effective Date: 12/30/2019
Version Issued Date: 12/30/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.