Question IP VS OP Status

[djurado@uic.edu]

Good afternoon,

I have a patient who was scheduled for OP surgery. Case was approved as OP with evicore for date 07/25/2025. The patient subsequently was admitted. The admit date is 07/27/2025 and IP auth approved with BCBS starting 07/27. The surgery was billed with POS 21 and of course denied for no authorization. Should we be billing the surgery as OP because the patient wasn't technically admitted until 07/27? I am being told we should bill as OP but I disagree. Thank you!

 

[sls314]

Good afternoon,

I have a patient who was scheduled for OP surgery. Case was approved as OP with evicore for date 07/25/2025. The patient subsequently was admitted. The admit date is 07/27/2025 and IP auth approved with BCBS starting 07/27. The surgery was billed with POS 21 and of course denied for no authorization. Should we be billing the surgery as OP because the patient wasn't technically admitted until 07/27? I am being told we should bill as OP but I disagree. Thank you!

Judging from your user name, I'm guessing you may be referring to BCBS Illinois.

This link is a document from BCBS Illinois regarding outpatient services within 3 days of an inpatient admission: https://www.bcbsil.com/docs/provider/il/standards/cpcp/2025/cpcp038-6-20-2025.pdf

It all depends on whether the outpatient services were related or unrelated to the inpatient admission, or whether the outpatient services were one of the defined exclusions.

Hopefully the document gives some additional guidance and clarity for you!

 

[djurado@uic.edu]

Judging from your user name, I'm guessing you may be referring to BCBS Illinois.

This link is a document from BCBS Illinois regarding outpatient services within 3 days of an inpatient admission: https://www.bcbsil.com/docs/provider/il/standards/cpcp/2025/cpcp038-6-20-2025.pdf

It all depends on whether the outpatient services were related or unrelated to the inpatient admission, or whether the outpatient services were one of the defined exclusions.

Hopefully the document gives some additional guidance and clarity for you!

Hello, yes this is BCBS IL Community (Medicaid product). However, the patient was not discharged post surgery. Status went from OP, OBS, IP during the same stay. I was always told to bill the surgery according to the final place of service, in this case being IP. is this correct?