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Meet criteria to receive APC payment for G0379

APCs Weekly Monitor, April 21, 2006

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Meet criteria to receive APC payment for G0379

QUESTION: I have a question regarding one of the new observation G codes. We understand that G0378 (hospital observation service, per hour), must be on all observation claims regardless of diagnosis, along with the inclusive hourly charges and revenue code 762.

However, what is the correct submission for G0379 (direct admission of patient for hospital observation care)? Should we associate a dollar amount with G0379? If so, how should we determine that dollar amount? Should we report $1.00 to pass claims edits?

ANSWER: Understand that G0379 is used to report those patients in observation status who have bypassed the ED or clinic. In order to receive separate APC payment for a direct admission to observation (APC 0600, $52.37 unadjusted national payment), the claim must contain the following two criteria:

1. HCPCS code G0378 (hourly observation). Report the total number of hours of observation in the "units of service" field.

2. HCPCS G0379 (direct admit to observation). Report this code with a unit of one. Make sure G0379 and the hourly observation code G0378 both have the same date of service.

Also consider these other important points:

• Watch for other services with a status indicator T, V, or critical care (APC 0620) provided on the same day of service as HCPCS code G0379. Note that although you will not receive APC payment for G0379 if you also report charges along with a status indicator T or V HCPCS code, it is important to report these charges if indeed they occurred, are documented, and the reported HCPCS codes conform to coding guidelines.
• Observation care for the direct admission must not qualify for separate payment under APC 0339. The three admitting/principal diagnoses that qualify for separate APC payment are chest pain, asthma, or CHF.

The national co-beneficiary payment for direct admit to observation is $10.47. It is imperative to create a facility charge that represents the resources of placing the patient in direct observation status, retrieving the medical record, and communication between physician and nurses.

Charging $1.00 for the services in order to pass internal and external billing edits will compromise future APC payments and creates a conflict that will result in co-beneficiary payments that are higher than the facility charge.

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