CurrentBlue Cross Blue Shield - MainePolicy C-11005

Outpatient Observation Services (facility)

Defines reimbursement rules and billing requirements for hospital outpatient observation services for commercial members; applies to providers submitting claims to Blue Cross Blue Shield - Maine unless superseded by provider, state, federal, or contract requirements.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyOutpatient Observation Services (facility)

Policy CodePolicy C-11005

Change TypeNo material change

Effective DateFeb 1, 2026

Next Review Date

Key ActionOrder and document observation with a written 'admit to observation' order and bill revenue code 0762 with HCPCS G0378 on the appropriate type of bill.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8-48standard observation time

0762+G0378required billing combo

G0379-banmutually exclusive

013X/078X/085Xaccepted type of bill

GA/KY/WIstate exemptions

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Observation Services — Coverage Criteria & Exclusions

Observation coverage criteria and exclusions

Observation services may be eligible when documentation and billing meet policy requirements and when clinical criteria are met. State-specific exemptions modify time windows or billing combinations.

ALL of the following

Written order stating 'admit to observation'
Order must clearly state 'admit to observation'
Medical record documents specific problem, treatment and expected frequency of skilled service

ALL of the following

Observation status must be at least 8 hours and no more than 48 hours
Subject to state exemptions (see state-specific variations)
Revenue code 0762 must be billed with HCPCS G0378 on a claim with type of bill 013X, 078X, or 085X
All observation services must be billed on one claim line with no date span and include the total number of hours in observation

Clinical indications (one or more)

Active care or further observation is needed following emergency room care to determine if the member is stabilized
Complication from an outpatient surgical procedure requiring additional recovery time beyond normal recovery
Care required is initially at or near the inpatient level

ALL of the following

When billed, HCPCS G0379 cannot be billed with CPT 99281-99285, G0380-G0384, G0463, or 99291 on the same claim
Revenue code 0762 must be billed with HCPCS G0378 along with 99281-99285, G0380-G0384, G0463, 99291, or G0379 on claims with more than 8 and less than 48 hours (except where state exemptions apply)

Exclusions (any of the following make observation inappropriate)

Physician, member, or family convenience
Routine preparation and recovery for diagnostic, therapeutic, or surgical procedures
Social issues
Blood administration
Cases routinely cared for in the Emergency Room or Outpatient Department
Routine recovery and post-operative care after outpatient surgery or standing orders following outpatient surgery

State-specific variations

Georgia: observation must be at least 8 hours and must not exceed 24 hours
Kentucky: does not require a minimum of 8 hours or maximum of 48 hours; allows reimbursement of revenue code 0762 billed with HCPCS G0378 without accompanying ED codes (99281-99285, G0380-G0384, G0463, 99291, or G0379)
Wisconsin: does not require a minimum of 8 hours; allows reimbursement of revenue code 0762 billed with HCPCS G0378 without accompanying ED codes (99281-99285, G0380-G0384, G0463, 99291, or G0379)

ALL of the following

Services must meet authorization and medical necessity guidelines and be supported in the medical record; failure to follow coding/billing requirements may result in denial or recoupment

Observation Services - General

General applicability and limitations

ALL of the following

This policy is subject to federal and state laws and to the terms, conditions, and limitations of a member's benefits on the date of service

ALL of the following

Reimbursement policies may be reviewed and updated periodically at Anthem's discretion

ALL of the following

No part of this publication may be reproduced without permission from Anthem Blue Cross and Blue Shield

Codes, Billing Rules, and Timing

Observation and related ED/care codesHCPCS | CPTCovered

G0378	Hospital observation service, per hour. (Required for observation services)
G0379	Direct admission of patient for hospital observation care. (For observation service must be billed with G0378 and revenue code 0762)
G0380	Level 1 hospital emergency department visit provided in a type B emergency department. (For observation services must be billed with G0378)
G0381	Level 2 hospital emergency department visit provided in a type B emergency department. (For observation services must be billed with G0378)
G0382	Level 3 hospital emergency department visit provided in a type B emergency department. (For observation services must be billed with G0378)
G0383	Level 4 hospital emergency department visit provided in a type B emergency department. (For observation services must be billed with G0378)
G0384	Level 5 hospital emergency department visit provided in a type B emergency department. (For observation services must be billed with G0378)
G0463	Hospital outpatient clinic visit for assessment and management of a patient. (For observation services must be billed with G0378)
99281	Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional. (For observation services must be billed with G0378)
99282	Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. (For observation services must be billed with G0378)

1–10 of 14

1/2

Not specified in this sectionmixed

No codes listed

Observation duration — minimum and maximum

Minimum observation durationAt least 8 hours

Maximum observation durationNo more than 48 hours

State exemptionsState-specific variations may modify the time window (policy notes Georgia/Kentucky/Wisconsin exemptions) — follow state requirements

Policy revision frequency

Review cadencePolicy is reviewed and may be updated periodically at Anthem's discretion

Legal applicabilitySubject to federal and state laws and member benefit terms on date of service

Reproduction noticeNo part of the publication may be reproduced without permission

Order, Documentation, and Billing Prerequisites

Billing Rule

Billing and Authorization Requirements

Prior Authorization may be required by the member’s benefit plan or provider contract. Verify eligibility and obtain any required authorizations prior to providing observation services to avoid denial of payment.

Bill revenue code 0762 with an appropriate type of bill: 013X, 078X, or 085X.
When billing observation services for >8 and <48 hours, include HCPCS G0378 on the claim along with one of: 99281-99285, G0380-G0384, G0463, 99291, or G0379.
Do not bill HCPCS G0379 on the same claim with CPT codes 99281-99285, G0380-G0384, G0463, or 99291.
Bill all observation services on a single claim line with no date span and report the total number of hours in observation.

Documentation Required

Documentation and Order Requirements

Document and order requirements must be present in the medical record. The patient’s record must include a written order that explicitly states "admit to observation", the specific problem, and the anticipated treatment and/or frequency of skilled services. Observation status must be at least 8 hours and no more than 48 hours.

Observation services must be ordered by a physician or other licensed individual authorized by state law and facility bylaws to admit members or order outpatient tests.
Medical record documentation must demonstrate that observation services are required and describe the specific problem and expected skilled care.
Observation status length: minimum 8 hours, maximum 48 hours.

Note

Use and Updates

This reimbursement policy is subject to federal and state laws and the member’s benefit contract on the date of service. Policies are periodically reviewed and may be updated; providers are responsible for following the most current policy and verifying any payer- or contract-specific requirements prior to service.

The policy may be updated; confirm the effective policy version for the date of service.
Providers must comply with applicable state licensure, facility bylaws, and contractual requirements when ordering or billing observation services.
Reproduction or redistribution of the policy content is restricted per the payer’s copyright notice.

Key Definitions and Facility/Claim Types

Observation Services — definition and scope

DefinitionObservation services are a well-defined set of clinically appropriate services including ongoing short-term treatment, assessment, and reassessment while a decision is made whether inpatient care is required or the patient can be discharged

PurposeUsed to determine need for inpatient admission or safe discharge following ED care or procedure complications

Documentation requirementMust include written order stating 'admit to observation' and documentation of the specific problem and expected skilled service frequency

Type of Bill — accepted facility types for observation claims

Type of Bill 013XHospital Outpatient (accepted for observation claims)

Type of Bill 078XLicensed Freestanding Emergency Medical Facility (accepted for observation claims)

Type of Bill 085XCritical Access Hospital (accepted for observation claims)

Anthem trade names and affiliated entities (Maine)

Anthem trade nameAnthem Blue Cross and Blue Shield is the trade name used by multiple affiliated entities

Maine affiliateAnthem Health Plans of Maine, Inc.

Corporate noteIndependent licensees of the Blue Cross and Blue Shield Association; Anthem is a registered trademark of Anthem Insurance Companies, Inc.