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Spilt billing

CGRIFFIN

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We are an Internal Medicine Practice, and we have been doing split billing. We bill out the doctor charge and also bill out for the facility charge.

My question is this, if we see a "New" patient in our clinic, and the patient has been seen in the hospital and is established at the hospital, can we charge out a "New" patient visit since the patient has never been seen by our provider? We also bill under the same tax ID number as the hospital.
 

mitchellde

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13,308
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Columbia, MO
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I am unclear as to your arrangement here. Are you a physician clinic in a facility setting? Do you pay rent to the facility? Do you use POS 11 or 22?
 

mcaouette

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I am confused as to why you are billing under the hospital tax id number. Are you a physician's office that is located in the hospital and that is why you are billing under the hospital's tax id number? Does the physician have their own tax id number and NPI. If the patient was seen in the hospital but never seen by your provider in the hospital you can bill a new patient visit but if the provider saw the patient in the hospital than you need to bill an established patient visit.
 

Pam Brooks

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Local Chapter Officer
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2,061
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Dover Seacoast New Hampshire
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It sounds like you are doing provider-based billing; where your physician practice is considered an outpatient department of the hospital. The billing guidelines are murky for provider-based billing, but following CPT and CMS guidelines is always appropriate.

New patients are not entirely determined by TIN, but by specialty, according to CPT and CMS. If you look at the decision tree in CPT, (which also mirrors the CMS guidelines), then as long as your patient did not see a hospital employed internist at your hospital setting in the past 3 years, they are a new patient in your practice. If you have employed hospitalists, they are usually internists.

If you're billing an E&M facility charge on the UB (again, the guidlines for the facilty charges are vague; CMS simply recommends that you determine and document a clinical calculation to arrive at the code) you should probably bill an established patient code, since the patient is not new to the facility.
 

mitchellde

True Blue
Messages
13,308
Location
Columbia, MO
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It sounds like you are doing provider-based billing; where your physician practice is considered an outpatient department of the hospital. The billing guidelines are murky for provider-based billing, but following CPT and CMS guidelines is always appropriate.

New patients are not entirely determined by TIN, but by specialty, according to CPT and CMS. If you look at the decision tree in CPT, (which also mirrors the CMS guidelines), then as long as your patient did not see a hospital employed internist at your hospital setting in the past 3 years, they are a new patient in your practice. If you have employed hospitalists, they are usually internists.

If you're billing an E&M facility charge on the UB (again, the guidlines for the facilty charges are vague; CMS simply recommends that you determine and document a clinical calculation to arrive at the code) you should probably bill an established patient code, since the patient is not new to the facility.
The guidelines for the facility may seem murkey but they are not really. Each facility is required to arrive at their own set of guidelines to determine the hospital level of service. You do not use the physician 95 or 97 guidelines. The guidelines must be written down and part of the policy and procedures and must be followed exactly the same for every patient.
This is why I requested more information. If they are renting the office from the facility then there will not be a separate facility charge and the POS is 11. If the are simply based in the hospital clinic the the POS is 22 and facility charge will be submitted on the UB04.
 

Pam Brooks

True Blue
Local Chapter Officer
Messages
2,061
Location
Dover Seacoast New Hampshire
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Debra, the guidelines are murky. It's up to the facility to develop, publish and follow their own guidelines to make them clear. I think that was my point.

Me and 100,000 other coders would love to see crystal clear CMS guidelines. If you've found them, please send 'em along! :)
 
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