Wiki Outpatient facility E/M

[becka95]

I'm looking for a reference that outlines what is included in the facility E/M. We have a score sheet (AKA clinical level of care) but I'm looking for a reference that states what is considered "facility resources." I am putting together material for education on E/M's, including the use of modifier 25.

There is an article in the AAPC learning centers however, it's not recent. Most references I find via Google search brings me to Pro E/M's, not facility.

 

[Pam Warren]

Well, if you find one, that would be awesome, and I'd owe you dinner. The guidance isn't really out there. I'm assuming that this is with regards to a provider-based situation.

Medicare says only that you devise a system and stick with it consistently. Commercial payers don't recognize provider-based billing.

Facility resources are anything that isn't an MD/DO, APRN, PA, CNM, CRNA, Ph.D., Psy.D. LCSW or licensed masters level behavioral health clinician. In short, anyone who doesn't bill directly on a 1500 form. Ancillary staff (nurses, medical assistants), supplies and the work that they do are generally calculated as facility resources--but not for outpatient hospital clinics.

The E/M visit facility code is G0463 except for Emergency Department, so leveling isn't necessary in outpatient clinic E&M services. That code was effective in 2014. ACEP has a good resource for levelling ED codes on the facility side.

 

[williamsonjk]

Where can I find the information you referenced regarding ancillary staff, supplies & the work they do are not calculated as facility resources for outpatient hospital clinics?
Thank you
Jalita Williamson, CPC,CHONC,CPMA

 

[Pam Warren]

Where can I find the information you referenced regarding ancillary staff, supplies & the work they do are not calculated as facility resources for outpatient hospital clinics?
Thank you
Jalita Williamson, CPC,CHONC,CPMA

Since there's only the G0463 for reporting the outpatient facility E&M, that's already been calculated for you. So their work is inherently included in that code, unless they provide a separately billable service based on an order and established care plan.

 

[williamsonjk]

Thank you for your reply. We are an outpatient hospital facility for infusion. Our E/M is billed as a profession fee for the providers with POS 11 (99212-99215). We were instructed to bill G0463 as POS 19 for facility resources. I am trying to determine what documentation is needed in order to bill the G0463 regarding resources. Any information is very appreciated. Thank you!

 

[Pam Warren]

Thank you for your reply. We are an outpatient hospital facility for infusion. Our E/M is billed as a profession fee for the providers with POS 11 (99212-99215). We were instructed to bill G0463 as POS 19 for facility resources. I am trying to determine what documentation is needed in order to bill the G0463 regarding resources. Any information is very appreciated. Thank you!

You wouldn't report G0463 on a 1500 form with POS 19. That goes on the UB, billed by the hospital.

 

[williamsonjk]

We are billing G0463 on UB04 as we are outpatient hospital. The office visit is billed by the provider on a 1500 form as they are still an employee of a provider based office.

 

[Pam Warren]

We are billing G0463 on UB04 as we are outpatient hospital. The office visit is billed by the provider on a 1500 form as they are still an employee of a provider based office.

Good, that's correct. When you are working in a provider-based practice, the office is considered a department of the hospital. That means that for any professional visit billed in POS 19 or 22, there is not going to be any practice expense or malpractice expense RVU included in the professional payment. Only the work RVU is included. In order to obtain payment for that excluded expense, the hospital can bill on the UB for the work done in the hospital department. Hospital resources (the building, the staff, etc.) are being used. That's why the term "split billed" is used. There's a professional and technical component in provider-based billing for services not generally split. Like E&M.

I am unaware of any specific documentation requirements for the facility E&M, but that's because the professional E&M note written by the provider is sufficient. We're billing that E&M in two places: the physician work and the facility resources. So as long as you have a progress note to support your hospital E&M, you can bill the G0463 on the facility side.