Preadmission diagnostic and nondiagnostic outpatient services claims
UnitedHealthcare commercial provider contracts adhere to the “3-day (or 1-day) payment window” policy. We use certain Centers for Medicare & Medicaid Services (CMS) definitions when determining reimbursement for outpatient diagnostic and nondiagnostic services preceding an inpatient admission.
Preadmission diagnostic services, including clinical diagnostic laboratory tests, are always considered included in the inpatient admission and should be reported on the inpatient claim
Preadmission nondiagnostic services are considered included in the inpatient admission and should be reported on the inpatient claim unless the hospital attests that the nondiagnostic services are unrelated to the inpatient admission
Report the attestation on the outpatient claim for the nondiagnostic services using Condition Code 51
Examples of nondiagnostic services include emergency room, observation, surgical procedures and recovery room
Including all diagnostic and nondiagnostic services on the claim helps improve payment consistency.