Description
Observation services are the use of a bed and periodic monitoring and/or short term treatment by a hospital’s nursing or other staff. These services are used to evaluate a patient’s condition to determine the need for possible inpatient admission. Observation care provides a method of evaluation and treatment as an alternative to inpatient hospitalization. Observation services are member-specific and not part of a standard operating procedure or facility protocol for a given diagnosis or service.
Policy
Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse observation services according to the criteria outlined in this policy.
Reimbursement Guidelines
Reimbursement will be allowed for observation services billed between 8 and 48 hours and for a maximum of 3 days. Observation services must be provided on the same date of service or day after either an emergency department visit, clinic visit or critical care service to be reimbursed.
Observation services must be reported on a single line and the date of service for that line is the date that observation care begins. Observation services should not be reported with a date span or on separate claim lines even when the period of observation care spans more than one calendar day.
Non-Reimbursable
Observation services are not reimbursable when any of the following are applicable:
- Direct Observation Admission:
- Submitted without the base hospital observation service
- Submitted with critical care services
- Observation services:
- Performed for seven (7) or less hours
- Performed for greater than 48 hours
- Performed for greater than a 3-day period
- Submitted without Type of Bill 13x and 85x
- Submitted without an emergency department visit, clinic visit or critical care service on the same date of service or day before
Billing and Coding
Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.
