Wiki Physician billing in a CAH

[mdoyle53]

Can ER/ED physicians bill Medicare directly for services performed in a CAH?

It appears from my research the answer is yes but I am trying to find someone who has actual experience or direct knowledge.

Thanks in advance

Mike

 

[mitchellde]

It depends on whether you are a method II CAH.

 

[mdoyle53]

My understanding is it is a Method II CAH

 

[mitchellde]

then no he may not bill directly his charges go on the UB-04 with a 981 rev code.

 

[mitchellde]

thought this night be interesting reading for you:
Method II (Optional Method for Outpatient Services)
Cost-Based Facility Services Plus 115% Fee Schedule Payment for Professional
Services.—The BIPA legislation on payment for professional services at 115 percent of
what would otherwise be paid under the fee schedule is effective for services furnished
on or after July 1, 2001. A CAH may elect to be paid for outpatient services in any cost
reporting period under this method by filing a written election with the intermediary on
an annual basis at least 30 days before start of the Cost Reporting period to which the
election applies. An election of this payment method, once made for a cost reporting
period, remains in effect for all of that period and applies to all CAH services furnished
in the CAH outpatient department during that period. Under this election a CAH will
receive payment for professional services received in that CAH’s outpatient department
(all licensed professionals who otherwise would be entitled to bill the carrier under Part
B). Payment to the CAH for each outpatient visit will be the sum of the following:
· For facility services, not including physician or other practitioner, payment
will be based on 101 percent of the reasonable costs of the services. On the
Form CMS-1450, (or electronic equivalent) list the facility service(s) rendered
to outpatients along with the appropriate revenue code. Pay the amount equal
to the lesser of 80 percent of 101 percent of the reasonable costs of its
outpatient services, or the 101 percent of the outpatient services less
applicable Part B deductible and coinsurance amounts.
· On a separate line, list the professional services, along with the appropriate
HCPC code (physician or other practitioner) and one of the following revenue
codes - 96X, 97X, or 98X. Payment will be 115 percent of the physician fee