Dear Provider:
The State of Ohio released a revision to several OAC rules pertaining to hospitals. Below is a list of the OAC rules that have been updated, and their corresponding effective dates:
- OAC Rules: 5160-2-05, 5160-2-01, 5160-2-66 Effective 7/1/2017
- OAC Rule: 5160-2-65 Effective 7/4/2017
- OAC Rule: 5160-2-79 Effective 7/6/2017
- OAC Rules: 5160-2-75, 5160-22-01 Effective 8/1/2017
Specifically, the revision of OAC 5160-2-75, effective 8/1/2017, required Aetna to make a system configuration change regarding Observation service (Code G0378) maximum unit billing.
The new rule can be found here.
The specific language related to this notice can be found under section G, subsection (f), paragraph (iii) which identifies services that may be paid outside of EAPG.
(f) Observation services.
i. For dates of service during the interim period: payment for observation HCPCS code G0378 will be made using an average rate.
ii. Payments for observation services grouped to EAPG code 00450, 00500, 00501, or 00502, will be limited to one unit per day, and a maximum of two consecutive days, except as provided in paragraph (G)(f)(iii) of this rule.
iii. Payments for observation services reported with HCPCS code G0378 will be made for up to twenty-four units per day or forty-eight consecutive units (which could extend over a three-day period).
iv. Additional payment for observation services will be made in accordance with the discounting factors as determined by the EAPG grouper.
Aetna has followed this new rule and has established an edit around the Observation services. The edit went into place on 10/29/17. Aetna will not be going back to retro adjust claims previously submitted from 8/1/17 to present but all claims submitted post 10/29/17will be edited per this rule revision.
G0378 will be edited to deny claim lines where greater than 48 units of the service are billed in a 72 hour period. A claim with 50 units submitted will be handled by the system by splitting the claim into 2 additional lines allowing 48 units on the first split line and denying 2 units on the second created line. The claim will have 3 lines now; one line with the original amount submitted 50 units, another line with the approved 48 units, and a third line with the denied 2 units.
All G0378 services should be billed on the same date of service for the consecutive 3-day span. Example: 24 hours G0378 provided on 8/1/17 and 12 hours of G0378 on 8/2/17 would be billed as DOS 8/1/17 36 units of G0378.
Please do not hesitate to reach out to our Provider Services team with questions at 1-855-364-0974.
