Q&A: Criteria for packaged observation services

Q: What are the criteria for receiving the C-APC for observation services (8011)?

A: The C-APC for observation services makes a single payment for encounters that include a clinic or critical care visit along with observation if no surgical service is provided. The following are the criteria for payment of the C-APC for observation:
One of the following assessment visits billed on the same day or the day before observation care:

• A clinic visit billed with G0463
  • A Type A ED visit billed with 99281–99285
  • A Type B ED visit billed with G0380–G0384
  • A critical care visit billed with 99291
  • Direct referral for observation billed with G0379
• At least eight hours of covered observation care billed with G0378
• No status indicator “T” or “J1” service (surgical procedure requiring anesthesia, including local anesthesia) reported on the day of or the day before the observation care

The C-APC for observation pays for all services provided in the encounter and billed on the same claim with the visit and observation services, including diagnostic testing and drug administration services that would normally be paid separately.

For more information see, Patient Status Training Toolkit for Medicare Utilization Review, Second Edition.