BCBSTX Admission Type Definitions Grouper Version 33
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1 Shared NPI between Acute Care and Specialty Provider numbers NPI is not shared between Acute Care and Specialty Provider numbers Residential Treatment Center, Eating Disorder Inpatient DRG 876, Inpatient RC 0114 and/or 0124 Inpatient DRG 876, Inpatient Revenue 1001 Partial Day: Half Day Outpatient Revenue 0905, 0910 and/or 0914 Partial Day: Full Day Outpatient Revenue 0912, 0913 and/or 0915 Intensive Outpatient Revenue 0913 and/or 0905 Less Intensive Outpatient Revenue 0912 Contract Eff Date 8/01/2012 and After IOP (Intensive Outpatient Outpatient Revenue 0905 PHP(Partial Hospitalization Outpatient Revenue 0912 and/or 0913 Burn All DRG Cardiac Cath Lab Outpatient Revenue 0481 Primary diagnosis for Burn admission type overlaps into Trauma definition and will always group to Burn admission type. Page 1 of 5
2 Shared NPI between Acute Care and Specialty Provider numbers NPI is not shared between Acute Care and Specialty Provider numbers Residential Treatment Center Inpatient DRG Inpatient RC 0116 and/or 0126 Inpatient DRG Inpatient Revenue Code 1002 Partial Day: Half Day Outpatient Revenue 0906, 0910 and/or 0914 Partial Day: Full Day Outpatient Revenue 0912, 0913 and/or 0915 Intensive/Less Intensive Outpatient Revenue Code 0906 Contract Eff Date 8/01/2012 and After IOP (Intensive Outpatient Outpatient Revenue Code 0906 PHP (Partial Hospitalization Outpatient Revenue 0912 and/or 0913 Chemotherapy All DRG code , Excluded from Inpatient DRG Cap Dialysis Outpatient Hemodialysis Revenue 0821, 0825, 0829 Peritoneal Dialysis Revenue 0831, 0835, 0839 CAPD Revenue 0841, 0845, 0849 CCPD Revenue 0851, 0855, 0859 Emergency Room Outpatient Revenue 0450 through 0452 and/or 0459 Level 1 CPT/HCPCS Level 2 CPT/HCPCS Level 3 CPT/HCPCS Level 4 CPT/HCPCS Level 5 CPT/HCPCS Critical Care CPT/HCPCS Page 2 of 5
3 Emergency Room Non 24/7 Outpatient Revenue 0450 through 0452 and/or 0459 May include the following CPT/HCPC codes Level 1 CPT/HCPCS Level 2 CPT/HCPCS Level 3 CPT/HCPCS Level 4 CPT/HCPCS Level 5 CPT/HCPCS Hyperbaric Oxygen Therapy Outpatient Revenue Code and CPT/HCPCS Code Revenue Code 0413 and CPT Code 99183/G0277 Medical/Surgical ICU CCU All Inpatient Inpatient Revenue Revenue Revenue Assigned when one of the other defined Admission Types is not applicable. Neonatal Inpatient DRG Level 1 Revenue 0170, 0171, 0179 Level Level Level Other Any other R&B Code Observation Outpatient Revenue 0762 Outpatient Surgical Outpatient Revenue 0360, 0361, 0363 through 0366, 0368, 0369, 0490, 0499, 0750, 0759, 0790, and/or 0799 Page 3 of 5
4 Pediatric All Patient age 0-17 years All Pediatric admission type for patient age 0-17 years only applies if the patient is initially admitted as Medical/Surgical admission type. Physical Rehabilitation All DRG Revenue Provider Based Billing Claim Outpatient Revenue Code/CPT/HCPCS DRG and/or Revenue 0118, 0128, 0138, 0148, , E&M Office Visit CPT/HCPCS codes (including but not limited to , , , 99354, 99355, , , , 99429, 99450, , , 99499) Either the DRG or one of the Revenue codes must be present Based on contractual provision, Provider Based Billing Claims are not compensated by BCBSTX Radiotherapy All DRG Code 849 Excluded from Inpatient DRG Cap Transplant All DRG , , 010, 014, , 652 Trauma All ICD-10-CM Diagnosis Please refer to the Trauma ICD- 10-CM Diagnosis Code Listing on the Texas Website. Primary Diagnosis codes for Burn admission type overlaps into the Trauma definition and when billed will not be considered Trauma Page 4 of 5
5 Treatment Room Outpatient Revenue Code/ CPT/HPCPCS codes Urgent Care Outpatient Revenue Code or 0761, with appropriate CPT/HPCPCS codes representing the specific procedures performed or treatments rendered within the Treatment Room setting. Page 5 of 5
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