Wiki E/M Outpatient Question

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edavis7

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Hello, I would like to know if a provider sees a PT in an outpatient clinic (the clinic is attached to the hospital) and wants to be paid for his professional service. How would it be billed?

The outpatient clinic is billing for the facility services and the provider is also the rendering provider on the facilities claim.

I did bill a claim with 99214 POS 22 and the claim was denied for services already processed and paid.

Thank you for your help.
 
you cannot use POS 11 if the service was rendered in the outpatient clinic. IS the facility billing the pro fee on their claim? Some facilities do this with a revenue code for physician service I forget the number and then bill the facility fee under revenue code 510. So you need to know what revenue code(s) the facility is using (I think physician service is 980 but not sure) If the are billing the pro fee also then you need to get that from them. If not then you need to talk to the payer.
 
I checked with the hospital billing department and they are billing on a different scale. The hospital billed a 99213 with the provider as the rendering provider and the provider is billing 99214 for his professional services with POS 22 which was denied by Medicare stating services were already processed and paid.

Should I be using a modifier for the professional services or a different POS?


My research for outpatient clinics states POS 22 is correct but I'm confused as to why the claims are denying. Can the provider be paid for his professional services?

Thanks for your help.
 
edavis7 said:
I checked with the hospital billing department and they are billing on a different scale. The hospital billed a 99213 with the provider as the rendering provider and the provider is billing 99214 for his professional services with POS 22 which was denied by Medicare stating services were already processed and paid.

Should I be using a modifier for the professional services or a different POS?


My research for outpatient clinics states POS 22 is correct but I'm confused as to why the claims are denying. Can the provider be paid for his professional services?

Thanks for your help.
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the hospital will bill the facility charge using the same 99211-99215 codes as the provider, that is not what is causing the problem. The facility bills revenue centers, the clinic is a 510, they also have a revenue center for the professional such as 982 which is pro fee outpatient. So the facility UB-04 could have a 510 with the 99213 and a 982 with the 99214 which then would make your claim deny. If the facility only billed with the 510 and the 99213 then your claim should not deny unless another physician of the same specialty saw the same patient on the same day. But your POS is 22. Also the facility e&M does not have to match the physician E&M as different criteria is used to determine the level.
 
Just to clarify on this issue - is the 99211-99215 pro fee considered bundled if the UB-04 is paying on the facility charge with 99214? I am having this issue on a lot of our
office visits for our oncologists.
 
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