Health Information Management

Q&A: Submitting claims for observation services

APCs Insider, January 22, 2016

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Q: Did something change with the observation services Composite APC in 2016? The director of patient financial services says we no longer receive payment for it.

A: The observation services Composite APC (APC 8009) was replaced with a single comprehensive APC (C-APC 8011) for CY 2016. Along with the new C-APC comes new status indicator J2. Services assigned to J2 are considered to be adjunctive services and components of C-APC 8011, and this will result in a single payment for these services reported as part of the comprehensive observation services APC. The J2 designation and the payment are based at the claims level and not per date of service.
 
The good news is that the requirements to meet the observation services C-APC are the same as for the Composite APC (e.g., clinic/ED visit, 8 or more units of G0378, etc.). Even more good news is that the ED visit level requirement now includes all Type A and Type B ED levels and critical care; the level is no longer limited to the higher ED visit levels.
 
Be sure that all services provided continue to be reported to insure that all costs pertaining to the individual patient’s scenario are included in your claims data. CMS will continue to expect and rely on the claims data for rate setting under the OPPS.
 
For more information, see the Medicare Claims Processing Manual, Chapter 4, sections 10.2.1, 10.2.3, 10.4, 290.5.1. 290.5.2 and new section 290.5.3.
 
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Revant Solutions,in Fort Lauderdale, Florida, answered this question.



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