Wiki Hospital Based Clinic

[encomma-watson]

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?

 

[jkyles]

Hi there,
You will never use those modifiers with E/M services. Can you explain why you think you need a modifier?

 

[encomma-watson]

Hi there,
You will never use those modifiers with E/M services. Can you explain why you think you need a modifier?

The ProFee Billing Director at the hospital tells me that since this one particular office is an hospital based clinic, one diagnosis of the patient goes on a UB and the other E/M and diagnoses goes on a 1500, It is very confusing. When I spoke to the Lead Medical Doctor at the clinic, she did not have any knowledge of this. Their work around is very funky to me. So, I have requested to have a meeting with the Director of ProFee Billing, our lead medical doctor and my bosses so that we can iron this out.

 

[sls314]

The hospital would bill on a UB for the clinic charges, and the physician would bill on the 1500 for the provider's professional fee. That part is correct.

However, you wouldn't use the TC and 26 modifier, because they aren't appropriate for E/M codes. No modifiers are needed, actually.

On the UB, you'd use whichever Clinic Revenue Code was applicable along with the CPT code. (The facility's Chargemaster should already be set up with that information, so you shouldn't need to choose this yourself.)

Clinic Revenue Codes:

510 Clinic, other
511 Clinic, chronic pain center
512 Clinic, dental
513 Clinic, psychiatric
514 Clinic, obstetrics/gynecology (OB/GYN)
515 Clinic, pediatric
516 Clinic, urgent care
517 Clinic, family practice
518 Reserved clinic
519 Clinic, other

 

[sls314]

The ProFee Billing Director at the hospital tells me that since this one particular office is an hospital based clinic, one diagnosis of the patient goes on a UB and the other E/M and diagnoses goes on a 1500, It is very confusing. When I spoke to the Lead Medical Doctor at the clinic, she did not have any knowledge of this. Their work around is very funky to me. So, I have requested to have a meeting with the Director of ProFee Billing, our lead medical doctor and my bosses so that we can iron this out.

I'm confused at what you're saying about the diagnosis?

There is a clinic charge, that should be handled by the facility biller and go out on a UB. And also a physician charge, that should be handled by the professional biller and go out on a 1500.

The diagnoses should be the same on both claims.

Are you the physician coder? If so, I'm confused why you're also being asked to handle the facility billing. The facility should handle that.

 

[sls314]

You just need to make sure that the correct Place of Service is being billed. That's how the payer will distinguish whether to reimburse the facility or non-facility rate to the physician for the E/M code.