How are observation stays impacted by OPPS?
• When eight hours or more of observation care is provided in conjunction with direct admission for observation or a high level clinical or emergency department visit or critical care services, then payment may be made for the extended encounter of care. Extended assessment and management composite APCs may be paid regardless of diagnosis when the observation care is unrelated to a surgical procedure. • For OPPS exempt hospitals, up to 48 hours of outpatient observation services may be cost-shared. Observation hours exceeding 48 hours shall be denied. • Maternity observation stays will be paid separately under TRICARE APC T0002 using HCPCS code G0378 (hospital observation services by hour) if the following criteria are met: • Claim must have a maternity diagnosis as Principal Diagnosis (PDX) or Reason Visit Diagnosis (VRDX) • The number of units reported with HCPCS code G0378 must be at a minimum four hours per observation stay • No procedure with a SI of T can be reported on the same
