Wiki Provider Based Billing/Modifiers

[neecen]

Good afternoon,

I have two questions I am hoping to get help with.

I am new to provider based billing. I was told that if a patient sees one of our providers in office then goes to the hospital for labs, x-rays, etc., we have to financially combine those accounts on the billing side and send it out on one claim for Medicare/Medicaid. I am being told that one of the lab services aren't being paid. They are coming back with denial code CO 97. So my questions:

Is it correct that we need to combine the services of two separate facilities in provider based billing?

If so, is modifier XE appropriate to use for two separate facilities?

I appreciate any insight that can be provided.

Denise


UPDATE:

Based on the information below, it appears XE can be used if the distinct separate service took place in a separate facility.

[9:53 AM] Nimon, Denise
Hey Laura, see below. This seems to indicate that we should be appending modifier XE to the labs, x-rays, etc. Based on this, I feel we can rebill the claims with the modifier as well as appending it to all future claims. Thoughts?

Modifier XE​

This modifier tells the payer that the service is distinct because it occurred during a separate encounter on the same date of service as the bundled procedure.
Example:
The patient sees the otolaryngologist in the morning, at which time the doctor performs an evaluation and management (E/M). During the visit, the patient complains of nasal congestion and headaches and the doctor performs a diagnostic nasal endoscopy. The visit is coded:
99213-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. -Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
That evening, the patient experiences a severe nosebleed and goes to the emergency room (ER). The ER physician is unable to stop the bleeding and calls the otolaryngologist in. The otolaryngologist comes to the ER and performs an extensive control of the nasal hemorrhage with packing. This encounter in the ER for the otolaryngologist is coded:
30903 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method
CPT® 30903 is a National Correct Coding Initiative (NCCI) Column 2 code for 31231, meaning the two codes are bundled and not separately payable. Appending modifier XE to 30903 tells the payer that the procedure performed in the ER was a separate encounter from the diagnostic nasal endoscopy performed that same day in the office.

 

[thomas7331]

Good afternoon,

I have two questions I am hoping to get help with.

I am new to provider based billing. I was told that if a patient sees one of our providers in office then goes to the hospital for labs, x-rays, etc., we have to financially combine those accounts on the billing side and send it out on one claim for Medicare/Medicaid. I am being told that one of the lab services aren't being paid. They are coming back with denial code CO 97. So my questions:

Is it correct that we need to combine the services of two separate facilities in provider based billing?

If so, is modifier XE appropriate to use for two separate facilities?

I appreciate any insight that can be provided.

Denise


UPDATE:

Based on the information below, it appears XE can be used if the distinct separate service took place in a separate facility.

[9:53 AM] Nimon, Denise
Hey Laura, see below. This seems to indicate that we should be appending modifier XE to the labs, x-rays, etc. Based on this, I feel we can rebill the claims with the modifier as well as appending it to all future claims. Thoughts?

Modifier XE​

This modifier tells the payer that the service is distinct because it occurred during a separate encounter on the same date of service as the bundled procedure.
Example:
The patient sees the otolaryngologist in the morning, at which time the doctor performs an evaluation and management (E/M). During the visit, the patient complains of nasal congestion and headaches and the doctor performs a diagnostic nasal endoscopy. The visit is coded:
99213-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. -Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
That evening, the patient experiences a severe nosebleed and goes to the emergency room (ER). The ER physician is unable to stop the bleeding and calls the otolaryngologist in. The otolaryngologist comes to the ER and performs an extensive control of the nasal hemorrhage with packing. This encounter in the ER for the otolaryngologist is coded:
30903 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method
CPT® 30903 is a National Correct Coding Initiative (NCCI) Column 2 code for 31231, meaning the two codes are bundled and not separately payable. Appending modifier XE to 30903 tells the payer that the procedure performed in the ER was a separate encounter from the diagnostic nasal endoscopy performed that same day in the office.

If your office is a provider based clinic that is under the same TIN as the facility where any tests are performed, then yes, it's correct to combine the services for facility portions of both onto a single claim (the professional services will go on a separate claim). The only exception is if the two encounters are entirely unrelated to each other (in which case your facility may bill separate UB claims with condition code G0 to indicate two unrelated encounters if the guidelines have been met. But if the provider is sending the patient to the facility for the labs or other tests to be done on that same date, these are related, and so both the facility portion of the office visit and the facility's charges for those tests are going to be part of the same claim and this is not considered a separate encounter.

As to the denial of the lab, you'll need someone with a knowledge of the Medicare outpatient facility reimbursement to look at the claim and determine whether or not the CO-97 denial is due to the lab being a part of the APC rate for that encounter, or whether the lab CPT code is being denied as incidental to some other service billed on the same claim due to an NCCI edit. Typically, Medicare does not separately pay facilities for labs if another non-lab service that is reimbursed at a comprehensive APC rate was performed on that date - with few exceptions, labs are always considered inclusive to the APC rate paid for the primary service. If that's the case, then this is not a coding denial and adding XE modifier is not appropriate and is also not going to change the payment at all. On the other hand, if your lab is being denied as incidental to a more comprehensive service on that claim, such as another lab panel that already includes that test, then a modifier to unbundle that code might be appropriate if the documentation supports the use of that modifier. So you'll need to look more closely at your claim to see which situation applies in order to determine whether or not a modifier is appropriate.

In short, you can and should use a modifier to override an NCCI bundling edit between two or your codes when the documentation supports it, but you can't use a modifier to bypass Medicare's OPPS payment calculations when a particular service is considered inclusive to the comprehensive payment rate for the encounter as a whole.

 

[neecen]

If your office is a provider based clinic that is under the same TIN as the facility where any tests are performed, then yes, it's correct to combine the services for facility portions of both onto a single claim (the professional services will go on a separate claim). The only exception is if the two encounters are entirely unrelated to each other (in which case your facility may bill separate UB claims with condition code G0 to indicate two unrelated encounters if the guidelines have been met. But if the provider is sending the patient to the facility for the labs or other tests to be done on that same date, these are related, and so both the facility portion of the office visit and the facility's charges for those tests are going to be part of the same claim and this is not considered a separate encounter.

As to the denial of the lab, you'll need someone with a knowledge of the Medicare outpatient facility reimbursement to look at the claim and determine whether or not the CO-97 denial is due to the lab being a part of the APC rate for that encounter, or whether the lab CPT code is being denied as incidental to some other service billed on the same claim due to an NCCI edit. Typically, Medicare does not separately pay facilities for labs if another non-lab service that is reimbursed at a comprehensive APC rate was performed on that date - with few exceptions, labs are always considered inclusive to the APC rate paid for the primary service. If that's the case, then this is not a coding denial and adding XE modifier is not appropriate and is also not going to change the payment at all. On the other hand, if your lab is being denied as incidental to a more comprehensive service on that claim, such as another lab panel that already includes that test, then a modifier to unbundle that code might be appropriate if the documentation supports the use of that modifier. So you'll need to look more closely at your claim to see which situation applies in order to determine whether or not a modifier is appropriate.

In short, you can and should use a modifier to override an NCCI bundling edit between two or your codes when the documentation supports it, but you can't use a modifier to bypass Medicare's OPPS payment calculations when a particular service is considered inclusive to the comprehensive payment rate for the encounter as a whole.

Ah! This makes total sense. I will definitely take a closer look at the denials.
Thank you so much for your reply and sharing your knowledge.

 

[neecen]

Ah! This makes total sense. I will definitely take a closer look at the denials.
Thank you so much for your reply and sharing your knowledge.

I just had another thought...I was just told that the providers have a different TIN from the hospital. In this case, do we have to combine the services or can we bill them separate with the modifier XE? I apologize, I am new to this hospital and new to hospital billing so I am getting pieces of information from different individuals.

 

[thomas7331]

I just had another thought...I was just told that the providers have a different TIN from the hospital. In this case, do we have to combine the services or can we bill them separate with the modifier XE? I apologize, I am new to this hospital and new to hospital billing so I am getting pieces of information from different individuals.

It doesn't matter what the TIN of the providers is, the only thing that matters is whether or not the clinic where they are practicing is owned by the facility. If so, and if the facility is designating the clinic as a provider based location, then you can't get around this by use of modifier. Even if you didn't combine the services, Medicare would still combine them for you and the modifier isn't going to get you an extra payment if the denial is not bundling related. You can bypass NCCI edits with modifiers, but not multiple facility claims that are submitted by the same entity.

Again, this is NOT a denial, it's just the way that Medicare prices outpatient facility services, and you can't get around this with modifiers. Provider based clinics get a much higher reimbursement overall that independent physician offices, which is why facilities choose to designate their clinics as provider based in the first place. It's just that some services are not itemized out for separate payment under the outpatient payment system, but everything is factored into the APC case rates that are paid. Those labs are being reimbursed - you're just not going to see an individual payment on that line item.

 

[neecen]

It doesn't matter what the TIN of the providers is, the only thing that matters is whether or not the clinic where they are practicing is owned by the facility. If so, and if the facility is designating the clinic as a provider based location, then you can't get around this by use of modifier. Even if you didn't combine the services, Medicare would still combine them for you and the modifier isn't going to get you an extra payment if the denial is not bundling related. You can bypass NCCI edits with modifiers, but not multiple facility claims that are submitted by the same entity.

Again, this is NOT a denial, it's just the way that Medicare prices outpatient facility services, and you can't get around this with modifiers. Provider based clinics get a much higher reimbursement overall that independent physician offices, which is why facilities choose to designate their clinics as provider based in the first place. It's just that some services are not itemized out for separate payment under the outpatient payment system, but everything is factored into the APC case rates that are paid. Those labs are being reimbursed - you're just not going to see an individual payment on that line item.

I understand now. Thanks again for sharing your knowledge about this Thomas!

Have a great day!