|
FAQs
Outpatient hospital services are diagnostic, therapeutic,
rehabilitative, or palliative items or services that are
furnished by or under the direction of a physician or dentist
to an outpatient in an institution licensed and certified as a
hospital. Outpatient services may include scheduled
services, surgery, observation room and board, and
emergency services provided in an area meeting licensing
and certification criteria.
An outpatient is a patient who is receiving professional
services at a hospital for a period generally not to exceed
24 hours. An outpatient may be admitted to a room by an
attending physician for either daytime or overnight
observation.
SC Medicaid outpatient hospital services are paid by a fee
schedule.
Outpatient services are divided into three major
categories. The category and reimbursement types for
outpatient services are as follows:
- Outpatient Surgical Services —Reimbursement Type 1
- Outpatient Non-Surgical Services —Reimbursement Type 5
- Treatment/Therapy/Testing Services —Reimbursement Type 4
The outpatient fee schedule is designed to reimburse for
actual services rendered. Only one category of service,
based on the highest classification billed, is paid per claim.
Reimbursement is based on the fee schedule rate or the
charges reflected on the claim, whichever is less.
The fee schedule can be found in Section 4 of the provider.
Observation Services
Observation services are furnished by a hospital on its
premises and include the use of a bed and periodic
monitoring by a hospital’s nursing or other staff. Such
services must be reasonable and necessary to evaluate an
outpatient’s condition or to determine whether there is a
need for admission as an inpatient.
These services usually do not exceed one day and must
be ordered verbally and/or authenticated by signature
of a physician or another individual authorized by state
licensure law and hospital bylaws to admit patients to
the hospital. The period of observation begins when
the physician orders observation and when the
monitoring of the patient actually begins.
Observation ends when ordered verbally and/or
authenticated by signature of a physician or another
individual authorized by state licensure law and hospital
bylaws to discontinue such treatment.
The observation room revenue code (762 and 769) units
do
not
multiply. Each 24 hours of observation can be filed on
one claim for multiple dates of service. While observation
services usually do not exceed 24 hours, they may exceed
24 hours in some cases and are not explicitly limited in
duration.
Note:
In cases where the observation stay must span two
calendar days, to equal 24 hours, observation
should not be billed for both days.
Outpatient observation charges must be billed using either
revenue code 762 or 769 for up to 24 hours of continuous
service. The observation period shall commence when the
patient is formally admitted to an observation room. The
attending physician may admit the patient for daytime or
overnight observation. Observation charges may be
reimbursed in addition to the surgical and non-surgical
payment.
Observation days prior to an inpatient admission can be
billed as outpatient services when the observation stay is
unrelated to the inpatient admission, excluding the day of
admission. Bill the date the beneficiary was switched from
observation to inpatient status as the first day of the
hospital admission. Observation stays related to and within
72 hours of an admission are considered inpatient services
and are included in the inpatient DRG payment. Refer to
Section 3 of the provider manual for specific billing
instructions.
Observation should only be billed if the patient meets the
conditions for observation. Do not substitute outpatient
observation services for medically appropriate inpatient
admissions. Test preparation, whether performed by the
patient or the facility by itself, does not qualify for
observation and observation should not be billed
concurrently with the test. In addition, observation
services should not automatically be billed because the
time for normal recovery from a surgical procedure is
exceeded. Observation would be appropriate when the
recovery period exceeds normal expectations for the type
of surgery and when the patient’s condition requires
observation.
Prior Approval Info
SCDHHS contracts with a quality improvement
organization (QIO), Qualis, to
perform presurgical review of select surgical procedures.
Qualis will answer questions regarding
pending reviews
only
. General prior approval (PA) questions should be
directed to the appropriate program representative. Qualis
staff can be reached at (877) 717 - 8592.
All documentation must be mailed. Providers must send all
available information along with the request (
i.e.,
history
and physical, photographs, and recommendations).
Qualis will not accept medical review documentation via facsimile.
PA requests for beneficiaries enrolled in Physician Enhanced
Program (PEP), Medical Home Local Network (MHLN),
or hospice programs must receive a PA from these programs
before contacting the QIO.
PA requests for beneficiaries enrolled in a
Managed Care Organization (MCO) program must be
handled by the MCO only. At present, the Medicaid enrolled
MCOs are Select Health and Better Health Plans
(BHP). Select Health may be contacted toll free at (888)
559-1010. BHP may be contacted toll free at (800) 600-9007.
Requesting physicians are responsible for providing the PA
number to any facility or medical provider who will submit
a Medicaid claim related to the service.
A list of procedure codes requiring prior authorization from
Qualis can be found in Section 4 of the provider manual.
| 