Coding Corner: Take Advantage of Simpler Observation Coding Under OPPS

The 2006 G codes and the appropriate diagnosis codes are your keys to payment

Providing observation services to patients who qualify for separate payment boosts your facility’s reimbursement. Do you know the criteria that make the difference between a $50 direct admit and more than $400 for observation care?

As of Jan. 1, HCPCS codes G0244 (Observation care by a facility to a patient), G0263 (Direct admission of patient with congestive heart failure, chest pain or asthma), and G0264 (Assessment other than congestive heart failure, chest pain, or asthma) were discontinued and replaced with two new G codes, G0378 (Hospital observation service, per hour) and G0379 (Direct admission of patient for hospital observation care).

Along with these new codes came another change that made observation reporting under the OPPS much simpler. OPPS claims processing logic, rather than the coding staff at the facility providing the observation, now determines whether observation and direct admission services are packaged or separately payable, according to the Centers for Medicare and Medicaid Services Medicare Claims Processing Manual, Transmittal No. 787.

Under the OPPS, CMS reimburses G0379 at a rate equal to that of a low-level clinic visit (APC 0600) with a payment of $52.37. But if your patient meets the criteria for observation care G0378 under APC 0339, you’ll receive a base rate of $425.08.
Observe These New Codes
List G0378 when observation services are provided to any patient, regardless of patient condition, says Annette Grady, CPC, CPC-H, director of educational services with Coding Metrix. The units of service you indicate should equal the number of hours the patient is in observation, she says.

Keep track of time: The number of units reported with G0378 must equal or exceed eight  hours, says Deborah J. Grider, CPC, CPC-H, CPC-P, CCS-P, EMS, president of Medical Professionals Inc. in Indianapolis. Observation time begins with the patient’s admission to the observation bed, she says. Observation time ends when all clinical or medical interventions furnished by hospital staff and physicians, including follow-up care, have been completed. Additionally, one of the allowable diagnoses must be reported in order to secure APC reimbursement.

Report G0379 for patients who are directly admitted by a community physician without any associated visit to the emergency department, hospital outpatient clinic, or critical care services, Grady says.

Report G0378 and G0379 for all observation services whether they are paid separately or separately packaged into other services, Grider says.
Secure Reimbursement With These Diagnosis Codes
For you to receive separate payment for observation services under the Outpatient Prospective Payment System (OPPS) with APC 0339 (Observation), the patient’s diagnosis must fall into one of three categories, Grider says: chest pain, asthma and congestive heart failure.

To ensure proper reimbursement, [...]

- Published on 2006-08-17