Code Description Comments
036X Operating Room Rev Code CPT/HCPCS required.
045X Emergency Room Rev Code Use to bill all surgical procedures performed in the emergency room.
049X Ambulatory Surgery Rev Code CPT/HCPCS required.
0762 Observation Room Rev Code
082x–085x, 088x Dialysis Rev Codes
• Outpatient services will be reimbursed on a fee for service basis, unless otherwise specified.
• Outpatient services billed on a paper UB04 or electronic 837I, version 5010 - will only be reimbursed when submitted with both a revenue code and a valid CPT/HCPCS code. Claim lines submitted without a valid CPT/HCPCS code will not be separately reimbursed.
- Exception: CPT/HCPCS is not required for Observation Rev Codes 0760, 0762, or Dialysis Rev Codes 0821–0889.
Emergency Room Services
Emergency room (ER) care is reimbursed at a contracted rate, including:
• Facility services directly related to the services provided as part of the emergency room care.
• Procedure/s performed in the emergency room setting.
Harvard Pilgrim reimburses the following services separately from the contracted rate:
• Ancillary services such as laboratory, pathology, radiology, etc that support the services provided.
• Procedure/s performed outside of the ER setting (i.e., operating room, ambulatory surgery, clinic, treatment room).
Observation stay is reimbursed at a contracted case rate and includes all facility services provided as part of the observation stay including but not limited to pharmacy, supplies, and ancillary services, such as laboratory, pathology, radiology, etc. (Refer to Observation Stay for more information.)
Emergency room services preceding observation stay
When emergency room precedes an observation stay, the entire emergency episode is included in the observation reimbursement for inclusive payment according to the contracted observation rate.
Outpatient surgery/significant procedures related to observation stay
• Observation services billed in conjunction with outpatient surgery or other significant procedures are considered part of the procedure and no separate observation reimbursement will be made.
Outpatient Surgery/Significant Procedures
Outpatient surgery/significant procedures are reimbursed at a contracted rate, including:
• Facility services that are directly related to the procedure performed including but not limited to anesthesia, operating room, recovery room, observations, implantable device, most pharmacy and supplies.
• Harvard Pilgrim reimburses the following services separately from the contracted rate:
- Ancillary services such as laboratory, pathology, radiology.