Wiki Help with ED billing/coding

[cathya35]

I am not familiar with ED coding/billing (risk adjustment coder here) and wondering if someone can help. I received a bill for my son's ED visit where he had a simple repair of a scalp laceration (CPT 12002). The procedure was billed twice, once for the professional component and once for the technical component. I don't understand the rationale for billing a technical component for this procedure and am wondering if this is correct. The provider (PA) simply stapled the scalp laceration (nothing else was involved). When I look up CPT 12002 in the MPFSDB it has a value of 0 under TC/PC, which I understand means that it cannot be split into professional and technical components? An E/M code was also billed for both the technical and professional component. Also, what is the usual fee schedule for an ED? Does it make sense that the fee we are being charged for CPT 12002 is about 5x the Medicare fee? Thanks for any help.

 

[mitchellde]

For an ED visit you willmreceice one Bill for the physician. This will include any evaluation if significant and the procedure. The procedure is being billed for the physician time and expertise otherwise known as the professional component. The facility will also charge the facility charge E&M which does not necessarily match the physician and also the procedure. The facility E&M will compensate the facility formthenroom and overhead and the procedure charge will compensate the facility for any additional staff and supplies needed otherwise known as the technical charge. So it is correct that the procedure was billed twice, there will be two different revenue codes if they put it all on one claim. One for the physician and one for the ER.

 

[danskangel313]

I am not familiar with ED coding/billing (risk adjustment coder here) and wondering if someone can help. I received a bill for my son's ED visit where he had a simple repair of a scalp laceration (CPT 12002). The procedure was billed twice, once for the professional component and once for the technical component. I don't understand the rationale for billing a technical component for this procedure and am wondering if this is correct. The provider (PA) simply stapled the scalp laceration (nothing else was involved). When I look up CPT 12002 in the MPFSDB it has a value of 0 under TC/PC, which I understand means that it cannot be split into professional and technical components? An E/M code was also billed for both the technical and professional component. Also, what is the usual fee schedule for an ED? Does it make sense that the fee we are being charged for CPT 12002 is about 5x the Medicare fee? Thanks for any help.

When you say the "fee" you're being charged, do you mean how much the facility billed your insurance for or how much you were left to pay?

Any balance due from the patient depends on a lot of things; who their insurance carrier is, if there's deductibles or coinsurances in play, the specifics within contractual agreements between health plans and facilities if such a contract exists, the type of plan you have... the list is endless. Also, even though the codes may be the same, the amounts charged out for the professional services will likely not match the amounts for the facility fees.

So you have the patient statement; does it show payments and adjustments or denials from your insurance company? If not, it usually means the claim is still pending with insurance. The exception is if you were balanced billed, meaning either A. you have no health insurance or B. you do have insurance but they didn't bill it.

Reading a patient statement can be really tricky for a lot of people, especially when it comes to situations where you have facility and professional fees separated and so forth. Send me a PM and I'll help guide you through things.

 

[Lisa Casey]

Help with ED billing / coding

WOW....that is thinking like a coder. All the comments on the reply thread seem spot on. BUT -- I would call both the ED Billing Company and/or the Facility Billing Company. Ask questions until you understand the billing. Also, call your insurance company. Have the claim number handy for one or both claims so the insurance agent will be able to review the billing with you. I hate paying for a bill with the uncomfortable feeling that I am being cheated.