Local Coverage Article Billing and Coding

Billing and Coding: Outpatient Observation Bed/Room Services

A56673

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Contractor Information

Article Information

General Information

Article ID
A56673
Article Title
Billing and Coding: Outpatient Observation Bed/Room Services
Article Type
Billing and Coding
Original Effective Date
07/11/2019
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

Title XVIII of the Social Security Act 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Outpatient Observation Bed/Room Services L34552.

Coding Information

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

For hospital outpatient billing only:

Group 1 Codes
CodeDescription
G0378 Hospital observation per hr
G0379 Direct refer hospital observ

Group 2

(11 Codes)
Group 2 Paragraph

For Critical Access Hospital billing only:

Group 2 Codes
CodeDescription
99221 1st hosp ip/obs sf/low 40
99222 1st hosp ip/obs moderate 55
99223 1st hosp ip/obs high 75
99231 Sbsq hosp ip/obs sf/low 25
99232 Sbsq hosp ip/obs moderate 35
99233 Sbsq hosp ip/obs high 50
99234 Hosp ip/obs sm dt sf/low 45
99235 Hosp ip/obs same date mod 70
99236 Hosp ip/obs same date hi 85
99238 Hosp ip/obs dschrg mgmt 30/<
99239 Hosp ip/obs dschrg mgmt >30

CPT/HCPCS Modifiers

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
XX000 Not Applicable

ICD-10-CM Codes that DO NOT Support Medical Necessity

N/A

ICD-10-PCS Codes

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

N/A

Other Coding Information

N/A

Revision History Information

Revision History DateRevision History NumberRevision History Explanation
01/01/2023 R3

Under CPT/HCPCS Codes Group 2: Codes added 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239 and deleted 99217, 99218, 99219, 99220. The code description was revised for 99234, 99235 and 99236. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/23.

10/31/2019 R2

This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Title XVIII of the Social Security Act 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim was removed from the CMS National Coverage Policy section of the related Outpatient Observation Bed/Room Services L34552 LCD and placed in this article.

07/11/2019 R1

All coding located in the Coding Information section has been removed from the related Outpatient Observation Bed/Room Services L34552 LCD and added to this article.

Associated Documents

Related Local Coverage Documents
LCDs
L34552 - Outpatient Observation Bed/Room Services
Related National Coverage Documents
N/A
Statutory Requirements URLs
N/A
Rules and Regulations URLs
N/A
CMS Manual Explanations URLs
N/A
Other URLs
N/A
Public Versions
Updated On Effective Dates Status
01/17/2023 01/01/2023 - N/A Currently in Effect You are here
10/21/2019 10/31/2019 - 12/31/2022 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Outpatient Observation Bed/Room
  • Outpatient Observation