§ 1150.56b. Payment policy for observation services—statement of policy.
(a) The Department will pay for clinically-appropriate and medically necessary observation services while a decision is made as to whether an MA beneficiary requires admission for inpatient acute care services or may be discharged to a nonhospital setting.
(b) Clinically-appropriate and medically necessary observation services include short-term treatment, assessment and reassessment that are furnished in the acute care general hospital outpatient setting.
(c) Observation services shall be prescribed or ordered prior to the acute care general hospital or practitioner rendering the service.
(d) The Department will pay acute care hospitals a one-time support component fee for observation services for a period of observation. The support component fee includes payment for all ancillary and diagnostic services provided during the period of observation.
(e) An acute care general hospital shall provide a minimum of 8 hours of observation services to be paid the support component fee.
(f) The Department will pay physicians, dentists and podiatrists a visit fee for observation services. The Department will pay physicians, dentists and podiatrists a separate professional component fee for ancillary and diagnostic services provided during the period of observation.
(g) Payments to physicians, dentists and podiatrists are subject to the conditions and limitations established in Chapters 1141, 1143, 1149 and 1150.
(h) The Department will not make payment for observation services in conjunction with the following:
(1) Short procedure unit surgical procedures, including surgical recovery time.
(2) Inpatient acute care general hospital services.
(3) Emergency room services.
(4) Hospital clinic services.
(5) Hospital physical therapy, occupational therapy and speech therapy services provided on any day other than the first calendar day of the period of observation.
(6) Special treatment room services.
(i) Physicians, dentists, podiatrists and acute care general hospitals shall comply with the recordkeeping and general standards for medical records requirements in § 1101.51(e) (relating to ongoing responsibilities of providers). In addition, physicians, dentists, podiatrists and acute care general hospitals shall include the medical record entries that are dated, with hour of entry noted, and signed.
Source The provisions of this § 1150.56b adopted June 24, 2016, effective July 1, 2016, 46 Pa.B. 3262.
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