Inpatient Hospital Requirements - DRG and Per Diem concept

Inpatient services are generally reimbursed based on one of the following:

• DRG, or

• Per Diem


Outlined below are generally accepted billing guidelines. This is intended to be illustrative and is not an all-inclusive list.

• The Admission Date field should reflect the true admission date for inpatient claims.

• The Statement Covers Period should reflect the beginning and ending service dates for the period included on the bill.

• Day of Discharge or Death is not counted as a covered day, unless admitted and discharged/deceased on the same day.

• For institutional claims with Bill Type 11X, the number of Covered Days is required and must be reported using "Value Code" 80.

Specifically, the number of Covered Days is a manual calculation of the length of stay by counting from the admit date to the day before discharge. Count all days except the day of discharge to get the patient's length of stay.

• Submit separate bills for mother and baby for obstetric and neonatal services.

• Reimbursement for newborn hearing screenings is included as part of the inpatient stay associated with a birth. It is the hospital’s responsibility to establish payment arrangements with physicians for the technical portions of this service if the necessary equipment is not available at the hospital.

• Submit one bill to Florida Blue upon member discharge, transfer or death.

• All charges related to a hospital admission, including any charges for outpatient procedures, surgical or non-surgical (including observation), incurred within 72 hours of an admission (unless otherwise specified in your contract) must be itemized on the UB-04 bill for the admission and will be included in the inpatient allowance.

• All relevant services that are part of an admission, including transfers within the hospital (e.g., from a medical surgical unit to a psychiatric unit or acute rehabilitation unit), should be included on one bill.


Exception: If separate contracts exist for a hospital’s DPU(s) and/or NPIs associated with any specialty unit or other hospital owned entity.


• Include charges for preoperative testing related to surgery on the same bill as the surgery, whether or not the testing was provided on the date of surgery. For an inpatient claim, the From Date and Admission Date will be different, as the Admission Date will be the date the patient was admitted to the hospital while the From Date reflects the date pre-operative services were performed.

• No interim or split bills.

• Bill physician/professional fees (0960-0989) on a CMS-1500 form.

• For hospitals that have a per diem contract, the revenue code that applies to the specific per diem room and board rate or medical condition should be used (e.g., maternity/OB admissions should be billed with the applicable room and board revenue code ending with a 2).

• Florida Blue can only accept claims with up to 12 diagnosis codes and up to 6 procedure codes.

• Diagnosis codes impacting the DRG assignment should be in the first through 12 diagnosis code position.

• Report only the ICD diagnoses codes corresponding to conditions that affect the treatment received and/or length of stay.

• If surgery is performed and a charge is made for the operating room, recovery room, or special procedure room, an ICD procedure code must be entered on all inpatient claims.

• POA Indicators are required for all primary and secondary diagnosis codes billed on inpatient acute care hospital claims.

• A private room is only covered if it is medically necessary or no semi-private room is available. The difference between the private and semi-private room rate is a non-covered amount and the patient's liability. For information on billing and reporting inpatient room and board refer to Coding a Facility Claim.

• Care associated with HACs, as defined by CMS, is taken into consideration when the DRG is assigned. Those coded with an “N” or a “U” indicator will be excluded from the DRG grouping.

• Beginning August 1, 2015 for claim submissions where the member is admitted to the hospital through the emergency room, non-participating BlueSelect hospitals and facilities should submit two separate bills (one for emergency services and another for inpatient services) so that Florida Blue can apply the in-network benefits to the emergency room services.


Note: The “U” indicator is subject to specific guidelines with regard to the patient status code before it is excluded from the DRG grouping process.

Services Included in the DRG or Per Diem Payment

Examples of items that should not be submitted as separate charges since they are included in the DRG or per diem payment, as applicable:

• Non-physician professional services, including all non-physician professional personnel time.

• Supplies routinely provided with a service or procedure (e.g., X-ray film, lab collection devices).

• Re-stock charges, processing fees and other direct administrative expenses. Pharmacy compounding equipment, supplies and fees (e.g., Laminar flow hoods).

• Any indirect expenses, including but not limited to housekeeping, dietary, plant and equipment maintenance, utilities and insurance.