4.2 For observation stays before
May 1, 2009 (implementation of OPPS) and thereafter for observation
stays in non-OPPS facilities, the following provisions apply:
4.2.1 Cost-sharing
of observation services, subsequent to ambulatory surgery reimbursement under
the prospective ambulatory group payment, is covered if determined
that placement on observation is medically necessary.
4.2.2 Cost-sharing
of outpatient observation services is covered following care provided
in an emergency setting.
4.2.3 Cost-sharing at the observation
level or outpatient level should be considered for inpatient denials
when the services rendered are medically necessary, but provided
at an inappropriate level of care.
4.2.4 Cost-sharing of outpatient
mental health observation is covered.
4.2.5 Up to 48 hours of outpatient
observation services may be cost-shared. Observation hours exceeding
48 shall be denied.
4.2.6 Time spent in a recovery room
following surgery should not be included in the 23 hour limit.
4.2.7 The time
of admission to an observation bed is counted as the first hour
of observation and is rounded to the nearest hour. The total number
of hours of observation should be indicated on one line in the units
field on the Centers for Medicare and Medicaid Services (CMS) 1450
UB-04 claim form. If the patient has more than 23 hours of observation
show all hours of services provided in the units field.
4.2.8 Outpatient
observation services are billed using the revenue code 0762 with
the description listed as Observation Services. This code includes
room and board services.
4.2.9 Up to 48 hours is considered
one stay and will cost-share/co-pay one time per claim.
4.3 For observation
stays on or after May 1, 2009 (implementation of OPPS), the following provisions
apply:
4.3.1 Outpatient observation stays are separately
payable when certain conditions are met for maternity patients.
Reference the TRICARE Reimbursement Manual (TRM),
Chapter 13, Section 2, paragraph 3.9.3 for
those specific conditions that must be met in order to receive separate
payment under the hospital Outpatient Prospective Payment System
(OPPS) for maternity observation stays.
4.3.2 All other observation stays
will be packaged under the primary procedure for payment. Hospitals
are to report these observation charges under revenue code 0762
- “Observation Room”, and HCPCS code G0378. The above packaging
requirement is specific for observation stays reimbursed under the
OPPS.