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 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 Healthcare Common Procedure Coding System
(HCPCS) code G0378. The above packaging requirement is specific
for observation stays reimbursed under the OPPS.