Wiki Billing for ER/ED facility fee

[yeissell]

Our facility has a type B Emergency Room. The facility has been billing (for NON-Medicare patients) both the ER/ED facility fees (G0381-G0384) and the E/M professional code for ER on the same CMS-1500 form. However, the insurances are denying the facility fee saying we are double charging.

My question is:
1. Can ER/ED facility codes G0381-G0384) be reported for non-medicare patients?
2. Should we bill ER facility fees on a CMS-1500 or on a UB-04?

Thanks,
NYG

 

[thomas7331]

Our facility has a type B Emergency Room. The facility has been billing (for NON-Medicare patients) both the ER/ED facility fees (G0381-G0384) and the E/M professional code for ER on the same CMS-1500 form. However, the insurances are denying the facility fee saying we are double charging.

My question is:
1. Can ER/ED facility codes G0381-G0384) be reported for non-medicare patients?
2. Should we bill ER facility fees on a CMS-1500 or on a UB-04?

Thanks,
NYG

It's been a while since I was involved with commercial payment on this type of a facility, but as I recall not all payers recognize or credential a type B emergency room as a freestanding facility. If that's the case, they likely will not accept the charges billed on a UB-04 form, but I imagine they also won't pay both of the charges on a CMS-1500 form either as their policy would likely be that the single professional fee is an all-inclusive payment. Whether or not they will accept the G codes will also depend on the payer.

If you are contracted with a payer, I think you will need to look at your contracts or contact them directly for guidance on their expectations for billing and payment, as well as what codes they accept. But if you are not in a commercial payer's network, then the patients can be held responsible for the denied charges and it would really be up to them to work with their plan to obtain payment.

 

[yeissell]

It's been a while since I was involved with commercial payment on this type of a facility, but as I recall not all payers recognize or credential a type B emergency room as a freestanding facility. If that's the case, they likely will not accept the charges billed on a UB-04 form, but I imagine they also won't pay both of the charges on a CMS-1500 form either as their policy would likely be that the single professional fee is an all-inclusive payment. Whether or not they will accept the G codes will also depend on the payer.

If you are contracted with a payer, I think you will need to look at your contracts or contact them directly for guidance on their expectations for billing and payment, as well as what codes they accept. But if you are not in a commercial payer's network, then the patients can be held responsible for the denied charges and it would really be up to them to work with their plan to obtain payment.

Thank you!!