55 Pa. Code § 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.
Notes
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