Billing Observation Hours in CC44 Scenario

djglenn1@att.net

I manage a team of Nurse Auditors. Per HCPro's "Medicare Compliance Essentials Training Compendium", page 54, it states (and/or implies) that in a Condition Code 44 scenario,the hospital may report and bill Observation hours, under revenue code 762, PRIOR TO the order for Observation status.  Currently, in a CC44 scenario, we charge OBS hours beginning with the Observation order for Medicare/Medicaid and MA plans. Commercial payers allow us to bill OBS hours from the original IP order forward. My question is...in a CC44 scenario, may we report and bill for Observation hours (Rev code 762) PRIOR TO the order for Observation status?    

dwilliamsrsi

You may, but without HCPCS code G0378.  Billable services with G0378 begin when there is a physician's order. However, CMS has recognized that when condition code 44 comes into play, there are hours prior to that time that involved resources and cost for the patient's care. So, you bill the hours but without the HCPCS code.  This is supported in the Claims Processing Manual (Pub 100-04). Chapter 1, section 50.3.2 - the last paragraph.  CMS even provides an example:"For example, a beneficiary is admitted as an inpatient and receives 12 hours of monitoring and nursing care, at which point the hospital changes the status of the beneficiary from inpatient to outpatient and the physician orders observation services, with all criteria for billing under Condition Code 44 being met. On the outpatient claim on an uncoded line with revenue code 0762, the hospital could bill for the 12 hours of monitoring and nursing care that were provided prior to the change in status and the physician order for observation services, in addition to billing HCPCS code G0378 for the observation services that followed the change in status and physician order for observation services."