Wiki Critical Access Method II billing ED Services

[Codinggma]

Good afternoon,

Receiving denials on commercial claims when billing for ED facility services on the UB and ED professional services on a 1500, the rendering provider is listed as the same on both claims. Has anyone experienced this and would be able to offer a solution? Is a modifier required on either claim to indicate they are separate (professional vs facility)?

 

[mansari@everestar.com]

No, you don’t need a special modifier to show these are separate services. The solution is to make sure the UB-04 is billed under the hospital/facility NPI and the CMS-1500 is billed under the physician/group NPI so the payer recognizes them as different claim types. I hope this iwll be of some help. Do let me know if you need more help and I can always connect you with our team of experts.

 

[Codinggma]

No, you don’t need a special modifier to show these are separate services. The solution is to make sure the UB-04 is billed under the hospital/facility NPI and the CMS-1500 is billed under the physician/group NPI so the payer recognizes them as different claim types. I hope this iwll be of some help. Do let me know if you need more help and I can always connect you with our team of experts.

Thanks so much for your reply. The ED physicians have reassigned their billing rights to the hospital, so the CMS 1500 is billed under the hospital NPI. The commercial payer is denying the charges as duplicates because the rendering is the same on both claims, and both are billed under the hospital NPI. Do you have any experience with this scenario? If we don't need a modifier to indicate professional vs facility charges, I'm wondering of all charges need reported on the UB like they are for Medicare.

 

[mansari@everestar.com]

Thanks so much for your reply. The ED physicians have reassigned their billing rights to the hospital, so the CMS 1500 is billed under the hospital NPI. The commercial payer is denying the charges as duplicates because the rendering is the same on both claims, and both are billed under the hospital NPI. Do you have any experience with this scenario? If we don't need a modifier to indicate professional vs facility charges, I'm wondering of all charges need reported on the UB like they are for Medicare.

Don’t move the ED physician charges onto the UB. Keep split billing: UB-04 for the facility; CMS-1500 for the professional. look like the duplicate edit is firing because you’re sending both claims under the same hospital billing NPI. Put the professional claim under a separate billing NPI (a hospital-owned physician group or a hospital subpart NPI), keep the physician’s rendering NPI in 24J, use POS 23, and list the facility’s NPI in Box 32 - also for compliance reasons. This could cause a big problem when get audited. That separation is what payers key on to distinguish facility vs. professional. If needed, your payer rep can confirm their duplicate‐claim edit logic and note that split billing should be adjudicated separately. CMS/Noridian guidance explicitly treats facility and professional as distinct claim types reported on UB-04 and CMS-1500 respectively. If you want, paste me one of the denial EOB messages (reason code/text). I can map it to the payer’s duplicate-edit rule and tailor the exact resubmission language. Shoot me email privately at mansari@everestar.om and I will try to get this answered for you.