Facility TC component and modifier 25

primrose1

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I posted this originally on the 'modifier' thread but didn't get a response :(; maybe someone here can advise?? Thank you!!!


Hoping someone can clarify for me as I'm confused. I've been billing in a private ortho practice for several years and we recently merged with a local hospital so we're now technically an outpatient facility. There are several insurance carriers that require split billing. What I'm told from the hospital billing dept is that a 25 is required on the TC component for the E/M portion of the claim if any x-rays are done here in the office which I've never had to do before. I'm not familiar with outpatient billing at all so I've been trying to do my own research on this and I'm confused with status indicators, etc., so sometimes I think yes and sometimes I think no. Most of the films we do in the office are listed on the CMS site as indicator Q1.

With that being said, is 25 required on the TC component of my E/M??? It's very confusing with the entire explanation of how all of these things work so I'm guess I'm looking for a straight 'yes' or 'no' and then maybe I'll 'get it'.

Thank you for any help in clarification!!!
 

primrose1

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Thank you for your help! I received a call from the hospital now that with the insurances that are split billed, if we take a patient to surgery the day they're seen or the next (i.e., for a fractured ankle), rather than putting a 57 modifier on the E/M, for the technical portion they're saying I have to put a 25 on their line of billing! This makes no sense to me at all! The guidelines for hospitals for the 25 & 57 modifiers are different as far as minor and major procedures? It's all very frustrating to say the least to try and re-train what I've done over the past decade!
 

mitchellde

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Hospitals do not use the 57 modifier that is a physician only modifier. The hospital facility outpatient will use the 25 if the facility used resources that are over and beyond what is necessary for the procedure. Jif the procedure is preplanned the the facility wil not bill an E&M at all. If the patient presented with an injury and the facility used resources such as their nurse and payient transporters to access the extent of the injuries and the provider then decided to take the patient to surgery then you would have an E&M and a 25 modifier. Remember the facility criteria for an E&M is completely different from the physician guidelines.
 

primrose1

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Thanks Debra for your help!!! I've been seriously debating signing up for the COC training/exam to see if that will clear up a lot of my questions. Do you happen to know if this is information that they would cover as far as E/M's and modifiers and when/what is appropriate??? I'm struggling making the transition to facility ways.
 

mitchellde

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I don't know, I never took the class! I know that if you research and read up on OPPS and APCS it will be very helpful. Also look up the outpatient code editor (OCE). Every quarter the CMS transmittals page has and update to the OCE and numerous transmittals on OPPS. These are very helpful. I was lucky to be working in outpatient from 1994 thru 2002. OPPS was implemented 2000 so I had a front seat on that one. There is a lot of information you can look up with just those seach words.
 
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