Question ER PHYSICIAN SERVICES

thomas7331

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94640 is an 'incident to' code (PC/TC indicator '5' on the Medicare Physician Fee Schedule) - it cannot be billed by the physician if performed in a facility. It would be a service performed by the staff, so would be part of the hospital's claim.
 

dorinda05

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Can anyone advise if 94640 is billable by the facility with an ER level for 2020 guidelines? They are receiving non covered denials, is it inclusive or should 59 modifier be appended?
 

thomas7331

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Can anyone advise if 94640 is billable by the facility with an ER level for 2020 guidelines? They are receiving non covered denials, is it inclusive or should 59 modifier be appended?
If the ER level supports a modifier 25, then 94640 is not inclusive and can be reported. Modifier 59 should not be necessary. However, it is a packaged service under OPPS reimbursement rules and inclusive in the ER case rates under many payer contracts, so it would not receive a separate line item payment in those situations.
 
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