Wiki Hospital based Clinic

encomma-watson

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Hello everyone, I have a question that has been bugging me for the last 2 months, I am the clinics Pro Fee Coder (about 5 clinics that I code for using the EPIC system). I work for a hospital in North Carolina and I have been told that the one clinic is a hospital based clinic. At this time, I have been told to use modifier TC for the first E/M (99202-99205/99212-99215) and modifier 26 for the 2nd E/M (99202-99205/99212-99215). For those of us you know, TC is technical components (used for Radiology or for special testing) as well as 26 modifier is the Professional component (for example 93010). Well, the providers that I work for do not do any special testing or do not read any special test (in example radiologist). Is there a modifier out there that I could use showing that our providers have seen the patient and that the hospital get the benefits of what we have done with the patient. Our providers are not hospitalist, they are family medicine and internal medicine and a couple of the providers have 2ndry specialty. Can anyone out there give me some help out here?
 
I'm not sure why you've been told to use the TC and 26 modifiers on E&M codes as that's clearly incorrect - as you've said, those are for diagnostic tests that include both a professional (interpretation) and technical component and E&M services don't fall into that category. It could be that these modifiers are used for internal purposes in your billing system, but they should not go out on the claims this way.

There's no modifier necessary on E&M codes to indicate the split bill - the payers will recognize this based on the place of service code and the type of claim form being submitted. If your clinic is billing a provider based (hospital based), then your provider just needs to bill the appropriate place of service code 19 or 22 to indicate that the services were rendered in a hospital, and the payers will know to reimburse just the professional portion. (The 'global' payment, or the payment that would include the costs of the office overhead, would be paid at a higher rate if you billed place of service 11). For Medicare, the hospital should be billing G0463 for their facility fee for the corresponding E&M code, not 99201-99215, but your system might covert these codes automatically. For a commercial payer, the hospital might bill the E&M codes 99201-99215 if the payer does not accept the G0463, but no modifier is necessary because the payer will know that this is just the facility fee because it is billed on the UB-04 form.
 
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