Wiki Facility

shorteep

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Does anyone know what code to bill for a facility fee for the office?
My doctor performs local procedures in the office and wants to bill the procedure codes but would also
like to bill a charge for the facility fee. Any help would be greatly appreciated

thank you
 
Yes, exactly as @jkyles@decisionhealth.com stated, if you are performing the services in office, then you are not a facility. When you look up RVUs and fee schedules for codes, there are different values for many codes depending on whether they are performed in a facility vs non facility. That difference is designed to reimburse the practice for the "practice expense" of doing the procedure in office. There are some codes that performing in office makes little difference in payment, yet incurs additional expense. Or some codes where the difference doesn't even cover the cost of the disposable equipment you use. You can make a business decision as a practice as to whether or not you are willing to perform those procedures in your office.
If you are truly creating a facility, there are a lot of rules and regulations. They vary significantly by state. For Medicare, you can only be a facility if you meet Article 28 guidelines (which an office will not). Many commercial carriers follow this same guidance. If (HUGE IF) the carrier allows you to credential as a facility, you would need a separate business, certification, and again coverage could vary widely based on payor. I suggest legal, compliance and accounting advice at a minimum. Way beyond the scope of knowledge for a coder.
 
Yes, exactly as @jkyles@decisionhealth.com stated, if you are performing the services in office, then you are not a facility. When you look up RVUs and fee schedules for codes, there are different values for many codes depending on whether they are performed in a facility vs non facility. That difference is designed to reimburse the practice for the "practice expense" of doing the procedure in office. There are some codes that performing in office makes little difference in payment, yet incurs additional expense. Or some codes where the difference doesn't even cover the cost of the disposable equipment you use. You can make a business decision as a practice as to whether or not you are willing to perform those procedures in your office.
If you are truly creating a facility, there are a lot of rules and regulations. They vary significantly by state. For Medicare, you can only be a facility if you meet Article 28 guidelines (which an office will not). Many commercial carriers follow this same guidance. If (HUGE IF) the carrier allows you to credential as a facility, you would need a separate business, certification, and again coverage could vary widely based on payor. I suggest legal, compliance and accounting advice at a minimum. Way beyond the scope of knowledge for a coder.
I know I'm a little late to this thread, but I have a similar question. Our director of operations want to bill a separate facility fee for our outpatient cancer center. There would be no medical decision making, just a flat fee regardless of the encounter type. What would be the best way to achieve this?
 
I know I'm a little late to this thread, but I have a similar question. Our director of operations want to bill a separate facility fee for our outpatient cancer center. There would be no medical decision making, just a flat fee regardless of the encounter type. What would be the best way to achieve this?

What place of service do you bill?
 
NOT an expert (or even a novice) for facility billing. However, if you are an outpatient cancer center billing POS 19 & 22, someone already took care of the legal/compliance/credentialing end of things. The services billed by the providers (likely E&M, maybe chemo, maybe rad onc) are being paid to the provider at facility rates, and not office rates. That is why your facility should be entitled to bill. HOW they bill is where my knowledge of this ends. There are plenty of facility billers on the forum who can hopefully provide that type of guidance.
In my organization, the profee coders bill for the physicians, and the facility coders bill for the facility.
 
What charges is the hospital currently billing on the UB-04?
Currently, we are billing a 99212 for established patients and 99202 for new if the patient comes in for a consult or follow up. If the patient only comes for infusion or labs, we bill 99212. Keep in mind, this is all the technical side. We're not having any issue with the professional fees.
 
Currently, we are billing a 99212 for established patients and 99202 for new if the patient comes in for a consult or follow up. If the patient only comes for infusion or labs, we bill 99212. Keep in mind, this is all the technical side. We're not having any issue with the professional fees.
Keep in mind that just as on a professional claim, facility charges must be backed up by documentation of a service - you can’t just bill a flat ‘facility fee’ just because the patient was there. For a clinic E/M visit with a physician, this is fine (though for Medicare patients it would be G0463, not 99202/99212) but if services other than an E/M were performed, you’ll need to use a modifier 25 to show that there was a separate service at that encounter. If the patient is only coming in for labs or an infusion and isn’t being evaluated by a physician, your facility shouldn’t be billing a separate E/M code.
 
Keep in mind that just as on a professional claim, facility charges must be backed up by documentation of a service - you can’t just bill a flat ‘facility fee’ just because the patient was there. For a clinic E/M visit with a physician, this is fine (though for Medicare patients it would be G0463, not 99202/99212) but if services other than an E/M were performed, you’ll need to use a modifier 25 to show that there was a separate service at that encounter. If the patient is only coming in for labs or an infusion and isn’t being evaluated by a physician, your facility shouldn’t be billing a separate E/M code.
I was just at HEALTHCON and Michele Stevens, in there class about outpatient billing, said that a clinic visit level of service can be billed with a lab visit.
 
I was just at HEALTHCON and Michele Stevens, in there class about outpatient billing, said that a clinic visit level of service can be billed with a lab visit.
Sure it can be billed with a lab visit, but it still has to be supported by documentation. Every code represents a service and a ‘visit’ can’t be billed unless some kind of service was provided and documented to warrant the use of that code.

Without having been at this class and not having heard the context of what was said, it’s hard to know exactly what was meant.
 
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