CurrentUnitedHealthcarePolicy 2025R6013C

Hospital Outpatient Observation Services (UB04)

Defines billing and reimbursement rules for hospital outpatient observation services reported on the UB04 form (or electronic equivalent) for UnitedHealthcare Commercial and Individual Exchange products, covering outpatient facilities including ASCs and OSCs.

Policy Summary

PayerUnitedHealthcare

PolicyHospital Outpatient Observation Services (UB04)

Policy CodePolicy 2025R6013C

Change TypeNo material change

Effective Date

Next Review Date

Key ActionReport G0378 under revenue code 0762 with units representing hours in observation care rounded to the nearest hour; units must be >= 8 to be considered for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

G0378primary facility observation HCPCS code described

G0379code for direct referral/admission to observation

>=8hminimum observation period for reimbursement

0762required revenue code

13X/78X/85Xallowed type-of-bill values

Observation Services Coverage Criteria

Observation services coverage criteria

Facility billing and reimbursement criteria for observation services (G0378/G0379):

ALL of the following

ALL of the following
- Report HCPCS code G0378 (hospital observation service, per hour) with units that represent the hours in observation care rounded to the nearest hour.
- Units reported for G0378 must equal or exceed 8 hours for the service to be considered for reimbursement.
Observation services must be reported on a single claim line where the date of service is the date observation care begins; do not span dates or report on separate lines when observation crosses calendar days.
Round start and end times to the nearest hour when calculating units (example rounding to nearest hour for unit calculation).

ALL of the following

ONE of
- Emergency Department visit (99281-99285 or G0380-G0384)
- Clinic visit (HCPCS code G0463)
- Critical care (CPT code 99291)
- Direct referral/admission for observation care reported with HCPCS code G0379 (G0379 must be reported on the same date of service as G0378)

ALL of the following

Do not report G0378 for monitoring that is inclusive of, or included in payment for, a surgical, diagnostic, or therapeutic procedure (for example, monitoring before a decision to proceed to surgery, during surgical recovery, or routine prep/recovery for a diagnostic test).
G0378 will not be reimbursed when reported in addition to procedure codes assigned a CMS IOCE status indicator of J1 or T.
G0379 is not separately payable when a critical care service (CPT 99291), clinic service (G0463), an emergency department visit, or a service assigned status indicator T or V under CMS IOCE are reported on the same date of service.
G0379 is intended only for direct community physician referrals to observation care and is not appropriate when the patient was admitted through the emergency department.

ALL of the following

Report G0378 under revenue code 0762; G0379 when used must also be reported with revenue code 0762 (do not use revenue code 0760 for G0379).
Report G0379 only when it is submitted on the same date of service as G0378; G0379 is not reimbursable if not submitted with G0378 on the same date.
When observation begins before midnight and ends after midnight, report G0378 on a single line using the date the observation began and report the total number of hours as units (example: begin 10:00 PM Friday, end 4:00 PM Saturday -> report single line with 18 units using Friday date).

Observation and Associated Codes

Covered observation and related facility/E/M codesmixedCovered

G0378	Hospital observation service, per hour
G0379	Direct admission for observation care
G0463	Hospital outpatient clinic visit
99291	Critical care, evaluation and management of the critically ill or critically injured patient
99281-99285	Emergency Department visits

Minimum reimbursable observation duration for G0378

Minimum reimbursable duration (units)8 hours — units reported for G0378 must equal or exceed 8 to be considered for reimbursement

Unit reporting conventionReport units as hours of observation care rounded to the nearest hour

Revenue code requirementReport G0378 under revenue code 0762

Type-of-bill valuesSubmit observation services on type of bill 13X, 78X, or 85X

When to Follow This Policy / Provider Responsibilities

Billing Rule

Scope — Use UB04 or electronic equivalent for outpatient facility claims

This reimbursement policy applies to services reported using the UB04 claim form or its electronic equivalent (or its successor form) for all products and for all outpatient facility claims, including Ambulatory Surgical Centers (ASC) and Outpatient Surgical Centers (OSC). Providers must submit observation services on the UB04 (or electronic equivalent) per the policy's billing rules (see coding and billing sections) when seeking reimbursement.

Key Definitions

Observation care

DefinitionObservation care: short‑term treatment, assessment and reassessment furnished while a decision is being made regarding inpatient admission versus discharge

Typical originCommonly follows presentation to the emergency department when additional monitoring or treatment time is needed

Applicable codesFacility observation services are reported with HCPCS codes G0378 and G0379

Direct admission (G0379)

DefinitionDirect admission (G0379): direct referral/admission to observation care without an associated ED visit, clinic visit (G0463), or critical care (99291) on the same date

When to reportReport G0379 only when the patient is referred directly to observation after being seen by a community physician and there is no same‑day ED/clinic/critical care service

Billing linkageG0379 must be submitted on the same date of service as G0378 and is not separately payable if conflicting services (ED, G0463, 99291 or IOCE status T/V) are reported the same day

Revenue codeReport G0379 with revenue code 0762 (not 0760)

Policy Summary

PayerUnitedHealthcare

PolicyHospital Outpatient Observation Services (UB04)

Policy CodePolicy 2025R6013C

Change TypeNo material change

Effective Date

Next Review Date

Key ActionReport G0378 under revenue code 0762 with units representing hours in observation care rounded to the nearest hour; units must be >= 8 to be considered for reimbursement.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Observation Services Coverage Criteria

Observation services coverage criteria

Facility billing and reimbursement criteria for observation services (G0378/G0379):

ALL of the following

ALL of the following
- Report HCPCS code G0378 (hospital observation service, per hour) with units that represent the hours in observation care rounded to the nearest hour.
- Units reported for G0378 must equal or exceed 8 hours for the service to be considered for reimbursement.
Observation services must be reported on a single claim line where the date of service is the date observation care begins; do not span dates or report on separate lines when observation crosses calendar days.
Round start and end times to the nearest hour when calculating units (example rounding to nearest hour for unit calculation).

ALL of the following

ONE of
- Emergency Department visit (99281-99285 or G0380-G0384)
- Clinic visit (HCPCS code G0463)
- Critical care (CPT code 99291)
- Direct referral/admission for observation care reported with HCPCS code G0379 (G0379 must be reported on the same date of service as G0378)

ALL of the following

Do not report G0378 for monitoring that is inclusive of, or included in payment for, a surgical, diagnostic, or therapeutic procedure (for example, monitoring before a decision to proceed to surgery, during surgical recovery, or routine prep/recovery for a diagnostic test).
G0378 will not be reimbursed when reported in addition to procedure codes assigned a CMS IOCE status indicator of J1 or T.
G0379 is not separately payable when a critical care service (CPT 99291), clinic service (G0463), an emergency department visit, or a service assigned status indicator T or V under CMS IOCE are reported on the same date of service.
G0379 is intended only for direct community physician referrals to observation care and is not appropriate when the patient was admitted through the emergency department.

ALL of the following

Report G0378 under revenue code 0762; G0379 when used must also be reported with revenue code 0762 (do not use revenue code 0760 for G0379).
Report G0379 only when it is submitted on the same date of service as G0378; G0379 is not reimbursable if not submitted with G0378 on the same date.
When observation begins before midnight and ends after midnight, report G0378 on a single line using the date the observation began and report the total number of hours as units (example: begin 10:00 PM Friday, end 4:00 PM Saturday -> report single line with 18 units using Friday date).

Observation and Associated Codes

Covered observation and related facility/E/M codesmixedCovered

G0378	Hospital observation service, per hour
G0379	Direct admission for observation care
G0463	Hospital outpatient clinic visit
99291	Critical care, evaluation and management of the critically ill or critically injured patient
99281-99285	Emergency Department visits

Minimum reimbursable observation duration for G0378

Minimum reimbursable duration (units)8 hours — units reported for G0378 must equal or exceed 8 to be considered for reimbursement

Unit reporting conventionReport units as hours of observation care rounded to the nearest hour

Revenue code requirementReport G0378 under revenue code 0762

Type-of-bill valuesSubmit observation services on type of bill 13X, 78X, or 85X

When to Follow This Policy / Provider Responsibilities

Billing Rule

Scope — Use UB04 or electronic equivalent for outpatient facility claims

Key Definitions

Observation care

DefinitionObservation care: short‑term treatment, assessment and reassessment furnished while a decision is being made regarding inpatient admission versus discharge

Typical originCommonly follows presentation to the emergency department when additional monitoring or treatment time is needed

Applicable codesFacility observation services are reported with HCPCS codes G0378 and G0379

Direct admission (G0379)

DefinitionDirect admission (G0379): direct referral/admission to observation care without an associated ED visit, clinic visit (G0463), or critical care (99291) on the same date

When to reportReport G0379 only when the patient is referred directly to observation after being seen by a community physician and there is no same‑day ED/clinic/critical care service

Billing linkageG0379 must be submitted on the same date of service as G0378 and is not separately payable if conflicting services (ED, G0463, 99291 or IOCE status T/V) are reported the same day

Revenue codeReport G0379 with revenue code 0762 (not 0760)

OpenPayer

Hospital Outpatient Observation Services (UB04)

Observation Services Coverage Criteria

Observation and Associated Codes

When to Follow This Policy / Provider Responsibilities

Key Definitions

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OpenPayer

Hospital Outpatient Observation Services (UB04)

Observation Services Coverage Criteria

Observation and Associated Codes

When to Follow This Policy / Provider Responsibilities

Key Definitions