Wiki Provider Based Billing

[neecen]

Good afternoon All,

I am new to provider based billing and to the hospital I am now employed. We are provider based however, the provider's TIN's are different from the affiliated hospital. I am being told that if one of our providers sees a patient in office, then sends said patient 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 to get the claim paid. So this is how they have been billing claims since becoming provider based. Can anyone verify this information? The reason this came up is that it was just noticed that the labs are being rejected. Per my manager, the rejection code is CO-97, labs are included in the APC rate for this charge. I checked with the billing manager to verify if the CO-97 denial is indeed due to the labs being a part of the APC rate for those encounters, or whether the lab CPT code is being denied as incidental to some other service billed on the same claims due to an NCCI edit. To her knowledge, the claims are being denied as being part of the APC rate for those encounters.

Any help is GREATLY appreciated!

Thanks,

Denise Nimon, CPC

 

[Pam Warren]

She's right. When you bill an outpatient service in a provider based hospital department, the APC rates (and rules) apply. Facility charges do not get reimbursed in the same fee-for-service method as if done in a physician office setting.

 

[neecen]

Thank you so much for your clarification.