Wiki outpatient facility coding for hospital (not inpatient)

[ltl226]

I was asked this question yesterday. I work for an outpatient facility and would be using outpatient codes. I was given codes 99203, 99204, 99213, and 99214.

Question: If we work in the hospital (not inpatient), for coding, do we need to use any modifiers or can we bill as normal and we’ll get facility rates? Also, can we bill E&Ms with a facility location? They are on the Medicare fee schedule?

 

[thomas7331]

Medicare no longer accepts the E/M code range 99201-99215 on outpatient facility claims - you'll need to use G0463 instead. The use of the modifier 25 applies the same to this code as it would to the regular E/M code if other services are billed on the same date. You physician claims for the professional services will still use 99201-99215 as appropriate, but you'll need to use place of service code 19 or 22, depending on whether the clinic is on-campus or off-campus. If you bill for off-campus services, you'll need to get guidance from your facility as to whether or not the site is excepted or non-excepted for provider based billing, and apply the appropriate modifiers for that as needed.

For non-Medicare payers, some will still accept 99201-99215 on facility claims, but many commercial payers do not have a site-of-service differential for E/M services performed in an outpatient hospital, so you'll need to look at your payer policies and contracts to determine the correct way to bill. Some commercial payers may require you to bill the entire E/M fee, including any facility charge, on the physician claim.

 

[SharonCollachi]

As a side note to what Thomas said, I find it disturbing that you were given only 99203-99204, 99213-99214. Those are not ALL of the E&M office visit codes, there are codes both lower and higher than those. So who exactly determined that you would not use the higher and lower codes, depending on what service was performed (rhetorical question).

I think what you're asking, is that if you bill an office visit code (99201-99215), will you automatically get paid for the facility. The answer is no. That has to be billed separately, as described by Thomas.

 

[ltl226]

Thank you both for such a timely response.

I have no idea what I was given those codes. There was not much information other than the above question.

Again, thank you both for your help. It is much appreciated.

 

[mjholodnik]

To piggyback off of the original question - I seem to recall a list on Medicare's website that used to provide what POS CPT codes could be billed. This was a number of years ago. For example, code 99205 could be billed in POS 11, 22, 24, etc. I have been searching for this information. Does this list still exist? If so, any idea where it can be located? Thank you in advance.