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.