Conscious sedation - facility vs physician?

[julrey]

Can a facility bill 99152 for conscious sedation or is 99152 only for the physician's professional fee? Any resources would be appreciated. Thanks so much!

 

[SharonCollachi]

The description of the code states that it is for the same physician as is performing the procedure. It is not for facility.

 

[thomas7331]

Although 99152 is a code used in conjunction with a procedure done by the same physician, it is not a 'professional component only' service and does have a facility/practice expense component, so it is appropriate for facilities to use this code to report their portion of the costs involved when that service is performed. There is usually no additional reimbursement involved for the facility from billing this since it is almost always an incidental service that is packaged into the case rates, but it is appropriate for reporting purposes.

 

[SharonCollachi]

One of my shortcuts is that I look up a CPT code on the Medicare fee schedule, and split the modifiers out. Medicare shows there is no professional component or technical component to this code, which is why I answered the way I did. So I was focused on billing it, not on any other cost reporting. I don't know if this information makes a difference.

 

[thomas7331]

One of my shortcuts is that I look up a CPT code on the Medicare fee schedule, and split the modifiers out. Medicare shows there is no professional component or technical component to this code, which is why I answered the way I did. So I was focused on billing it, not on any other cost reporting. I don't know if this information makes a difference.

Most CPT/HCPCS codes involve a practice expense component beyond just those that are split between a professional and technical component, so facilities do bill those codes for the portion that's eligible for reimbursement. For example, facilities will bill surgical procedure codes for the use of the operating room, even though surgical codes have no PC/TC designation. The only codes that are actually never recognized for billing by the facility are codes that represent a professional component only - such as 93010 (interpretation of EKG) - since there is the entire payment for this code goes toward a physician's professional service.

But I'd note that the physician fee schedule isn't a failsafe tool for determining what code a facility can bill or how they are paid - for the code status and indicator assignments that apply to facility billing, look instead to the OPPS files and addenda that are published by CMS each year.

 

[julrey]

Thank you both so much for that education I appreciate it.