Wiki Outpatient Provider Based Facility-CCM codes Reimbursement

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I am trying to find out the Part A facility reimbursement methodology for a provider based hospital owned outpatient clinic that is more than 250 yards from this hospital and started billing for services after November 2, 2015.

My understanding is that starting in 2017, the above described facility cannot bill addendum part B for Part A. The rules say that it would use either the PFS or ASC, however I am unclear on how this will be reimbursed.

Under this situation, which modifiers should be used? "PO"?
 
I think you have the A and B rules reversed here. Unless something has changed since I was last involved in this, off-campus provider based clinics that started billing after 11/2/15 may no longer bill as a facility in 2017, so there would be no Part A claim or reimbursement methodology. Claims for services at those locations would need to be submitted to Part B only, as physician practices with POS 11.

Off-campus clinics that were billing prior to that date were grandfathered - those can continue to bill a Part A claim for the facility with the modifier PO and a Part B claim for the physician with POS 19. The facility claims will continue be paid under OPPS using the same APC methodology as before - the PO modifier does not affect payment, it's only being used to collect information only at this time. Hope that helps.
 
Follow Up Question

So to clarify, non grandfathered in clinics can only bill for physician services (Part B), they cannot bill under Part A. Would they be paid under the Facility or Non-Facility fee in the Part B schedule?
 
That's correct. The claims will pay the non-facility rate - they reimburse at the higher rate because the practice expense costs that would otherwise have been paid to the hospital if the claim had been split are included in the payment for the Part B claim.
 
50% of Addendum

After doing more research, it looks like specifically for 2017, for chronic care management services, a physician working in a nonexcepted provider based department for a hospital owned clinic, would bill the facility fee for physician services and 50% of the APM (Part B Addendum) when billing the facility. I believe the goal of CMS is to only have Part B Billed as non-facility as you stated, but for 2017, per the Interim Final Rule with Comment Period, it would pay at 50% of OPPS APM (Addendum part B) when billing for the facility.
 
Yes, I've been learning about the new interim process a bit since my last post. The non-excepted provider based departments are to continue billing professional and facility claims this year - there were concerns about enrollment of hospital entities under Part B and implications for claims submission and payment. The physician claim will continue to pay at the facility rate and the facility claim will pay at the reduced rates as a prospective estimate of what the facility portion would be under the PFS. It looks like you'll need to use modifier PN for your facility claims for the non-excepted off campus departments in order to correctly report and be correctly reimbursed.

I haven't been involved in provider based billing since changing jobs last summer - sorry if I didn't give you current information before.
 
We are a physician office that uses Care managers that utilize the CCM codes. We are not a hospital entity, but we are a look-a-like Federally qualified health care organization. We use eclinicalworks EMR that has a module for purchase to capture this documentation and charges to maintain consistency and accuracy. With the dilemma I am hearing about for CCM reimbursement for 1/1/18, we are not sure if we should purchase the module...but they how do we get reimbursed for our care managers?
 
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