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Wiki Doctor's office VS. Outpatient Hospital
- Thread starter grivera
- Start date
mitchellde
True Blue
There are numerous differences can you narrow down what you are wanting to know?
Pam Warren
True Blue
For professional services, the Outpatient hospital is billed with POS 22
Office is billed with POS 11
This difference tells the payer that services provided in the office are subject to extra expenses that the provider has to cover: practice expense, such as rent, heat, staff, etc, and malpractice expense (premium). Services provided in the office are paid at a higher rate to allow for the additional expense for the provider to deliver services in that setting. When the physician works in the outpatient setting, these expenses are absorbed by the hospital, so the reimbursement by the payers is less.
Additionally, OP hospital (technical) services have different coding/billing rules than the physician office. Global days are different, some codes are different (technical vs. Professional), there are different modifiers in place, and outpatient services (not provided by a physician) are not billed on the 1500, but are billed out under OPPS on the UB form. E&M codes are billed, but they do not utilize the same measurement to determine the level of service. Bundling rules are not always the same, although certain supplies are not paid separately. Frequently, diagnosis codes are assigned based on reason for visit rather than the resultant report (physician interpretation/assessment/plan). This kind of coding/billing is very different from physician coding/billing.
Billing an outpatient service under POS 11 is one of those no-no's that the OIG is going after---hard!
Office is billed with POS 11
This difference tells the payer that services provided in the office are subject to extra expenses that the provider has to cover: practice expense, such as rent, heat, staff, etc, and malpractice expense (premium). Services provided in the office are paid at a higher rate to allow for the additional expense for the provider to deliver services in that setting. When the physician works in the outpatient setting, these expenses are absorbed by the hospital, so the reimbursement by the payers is less.
Additionally, OP hospital (technical) services have different coding/billing rules than the physician office. Global days are different, some codes are different (technical vs. Professional), there are different modifiers in place, and outpatient services (not provided by a physician) are not billed on the 1500, but are billed out under OPPS on the UB form. E&M codes are billed, but they do not utilize the same measurement to determine the level of service. Bundling rules are not always the same, although certain supplies are not paid separately. Frequently, diagnosis codes are assigned based on reason for visit rather than the resultant report (physician interpretation/assessment/plan). This kind of coding/billing is very different from physician coding/billing.
Billing an outpatient service under POS 11 is one of those no-no's that the OIG is going after---hard!