Question ESI facility vs office billing


Mesa, AZ
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Hi all, I've spent the day poring through Medicare sites to no avail. This is one of those questions that has a logical answer, but I'm looking for a source to document that the answer is correct. A physician billing for ESI usually has two component CMS bill for provider fees, and one UB for facility fees where the injection was performed. If a physician happens to do an ESI in his office, I understand the POS would show as 11. Is there anything in writing somewhere that he doesn't also get to add a "facility fee" to his bill when done in-office? Any Medicare source for this? Thank you in advance!


True Blue
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How is a physician going to add a facility fee to a 1500 claim? There is no CPT code for a facility fee. They can (and probably should) charge a higher rate for the procedure when done in the office if they want to, but that's not going to change how much Medicare is going to pay them.

If you look at the Medicare Physician Fee Schedule, for any given code for a service that can be performed in either an office or facility place of service, you will find two different payment rates - one is the facility rate and one is the non-facility rate. The non-facility rate will always be a higher payment rate because Medicare is compensating the physician for the cost of performing the procedure in the office. So the 'facility fee' for any office procedure is already encompassed in the higher rates that Medicare sets for those procedures. But you can't charge any separate facility fee outside of what's billed for the office procedure because there's simply no way to do that which will get Medicare to make a separate additional payment.