Forum - Questions & Answers

Jun 25th, 2009 - macc

Billing E/M in an outpatient facility

When a patient is seen in a hospital, as an outpatient, can both the hospital and the physician bill an E/M service? If so, do both the hospital and the physician need to bill the same CPT code and should a modifier be added? I have a physician that sees patients in a hospital sleep lab before they are scheduled for a sleep study. The hospital tells me that they are billing an E/M code because it is in their facility and they are doing the vitals before the physician sees the patient. We are also billing an E/M code for evaluating the patient. Please advise.

Jun 25th, 2009 -

Tell the hospital to BACK OFF or else!

They cannot charge the E&M! E&M billing requires both an E and an M. Vitals are part of the E but there is no M involved. I am sure there is miscommunication- they charge a facility fee and the doc charges the E&M. Talk to the billing dept to get it straight. And if they insist on billing the E&M, call CMS Fraud hotline and save my tax dollars.

Jun 25th, 2009 - nmaguire   2,606 

Facility setting E/M

When an E/M is performed by physician in a hospital outpatient setting, the hospital will bill a Revenue code (520 for the clinic visit) and will put a level of E/M on the UB. This is the facility component of the E/M encounter. The hospital will receive reimbursement for the facility component and the physician will received a reduced amount for the E/M performed by a physician in a facility.

Jun 26th, 2009 -

i don't get it

How does the hospital report an E&M? What code do they use? Do they guess what code the doc will report and use that? Do they have their own codes or use our 99xxx? If they report one code and the doc reports a higher level code, does it create an audit target?

Jun 26th, 2009 - nmaguire   2,606 

E/M facility

The facility may generates an E/M level assignment based on nursing documentation. The levels are assigned in different ways: Several types of mapping systems: Intervention based model; Point based model; Time based model; The mapping system may be dependent on existing documentation. this is a method of reporting what charges are appropriate for facility expenses. Reimbursement will be based on APC methodology.

Jun 26th, 2009 - nmaguire   2,606 

APC payment examples

APC 8002-- Level I Extended Assessment and Management Composite

APC 8002-- Level I Extended Assessment and Management Composite
This APC requires a level 99205 or 99215 clinic visit on the day of or the day before observation or a direct admission to observation. In addition, at least 8 units of G0378 (Observation services, per hour) must be reported and no procedure with a status indicator of T (significant procedure subject to multiple procedure discounting).

APC 8003—Level II Extended Assessment and Management Composite

This APC requires a level 99284 or 99285 Type A ED visit, a G0384 level 5 Type B ED visit, or 99291 critical care to be reported on the day of or day before observation. In addition at least 8 units of G0378 (Observation services, per hour) must be reported and no procedure with a status indicator of T (significant procedure subject to multiple procedure discounting).

These composite APCs are reimbursed in a single payment for the combination of an ED or clinic visit with observation instead of a separate payment for both the observation and the ED or clinic visit. APC 8002 payment is $375.70 and APC 8003 payment is $674.73.

Jun 26th, 2009 -

These sound like Observaton sevices

when the patient is placed in the hospital as an outpatient. Does this also apply to outpatient clinic visits like an outpatient oncology clinic or a sleep center where docs can see patients like in their office?

Jun 26th, 2009 - nmaguire   2,606 

facility

the hospital will bill facility charges for any encounter listed as an outpatient facility place of service.

Jun 28th, 2009 - dsteed   141 

E & M in Hospitals

Hospitals will bill for E & M only in clinics and emergency department. Their calculation method is very different from physicians. It has nothing to do with exam, history, MDM, but is based on utilization of resourses. This is most typically accomplished by using a point system. Each hospital will determine the points assigned to each service, with further determination as to how many points equate to a certain code level. It is not necessary for the code to be the same as the physician's code, as the reporting is captured by different methods. This is the way that hospitals capture revenue for their nursing personnel, techs, use of room, set up & clean up in clinics and emergency depts.

Jun 29th, 2009 - KSnowden 1 

E&M in Hospitals

Where can I find the regulations that spell out the calculation method used for E & M billing in for outpatient clinics?

Jun 29th, 2009 - nmaguire   2,606 

facility billing

This will differ per institution. each facility maps differently

Jul 3rd, 2009 - dsteed   141 

Billing Facility E & M

I have just posted an entry about this calculation. Should be available when released by the editors.

Aug 3rd, 2009 - stephesj 9 

E&M in hospitals

You can download the 95 and 97 from this link:
http://www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp

Aug 1st, 2009 - SuzCook1946 4 

facility billing and E&M

When a hospital is qualified for "outpatient hospital department" status by Medicare, the professional providers who work there bill for their E&M services on a CMS/1500 professional billing form to Medicare part B and some other insurance carriers. The provider selects the E&M code range and level consistent with her services to the patient. Location of service is called "outpatient" and not "doctor's office".
The hospital/facility bills Medicare part A on a different form called a UB for a different "service", i.e., for the cost of providing the sticks and bricks...the outpatient clinic building, nursing services, receptionists and supplies furnished by the facility. The bill lists an E&M code in addition to the revenue code which Nancy mentioned above, and the facility's E&M code does not have to match the professional provider's code.
This is not "double dipping", it is how Medicare pays for the global service a patient receives in an hospital outpatient department setting.



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