Can a hospital and provider (not employed by hospital) both code 99285 and bill separately (care does qualify for this code)? I also have questions about separate pharmacy, IV, PACU medications (billed by the hospital) that in my opinion should be included in the OR/Surgical codes. I've attached the bill, if anyone has time to review and advise, I would really appreciate the help. This is a self pay patient. I am a new CPC. Thanks!
Yes, both the facility and the provider would charge for an ER visit. The provider's fee is for the provider's time and expertise. The facility's fee is for the expenses associated with use of the ER (nursing staff, overhead for the room itself, etc.).
Hospital claims do separately list the charges for pharmacy, IV, supplies, PACU, and any other services received. An insurer contract may reimburse a DRG or case rate, but the hospital still has to include all charges on the claim.
This specific itemized statement is for an inpatient stay. You can see that by the Revenue Code 121 charge for one night's room. From a quick review of the itemized statement, I'd guess that the patient originated in the ER, had surgery, and was admitted overnight.
There's nothing about the itemized statement that jumps out to me as unusual on a quick review.
If I were going to dig into the charges further, I would compare the itemized statement to the hospital chart records. Determine whether all of the pharmacy, supply, and lab charges are documented in the chart. If any particular item wasn't documented in the chart, I'd ask for it to be removed from the bill.
If I were trying to help someone reduce their self-pay bill, I'd find out what the DRG would have been for this inpatient claim. I'd then find out what the hospital would be reimbursed by Medicare and Medicaid for that DRG. (Medicare and Medicaid reimbursement is published on the websites, so that's why those are most often used as an approximation.)
Then I'd try to negotiate the patient's liability on the claims to be somewhere in the ballpark of what Medicare/Medicaid would pay for the same services. That's not an unusual tactic - when I worked for a large hospital system, I'd often be asked to research what the Medicare or Medicaid would reimburse for a service, so that the hospital finance people could negotiate with a self-pay patient and/or the patient's attorney.
I see that a self pay discount of $8,165.75 was taken on the service. Was that the automatic self-pay discount, or did the patient complete financial assistance forms? If the patient has not completed financial assistance forms with the hospital, I'd recommend they do that. They may qualify for a bigger discount.
If you have any other questions, I'd be happy to answer to the best of my ability.