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Coding when practice is bought by hospital

  1. Default Coding when practice is bought by hospital
    Medical Coding Books
    My question is my husbands cardiologist group was bought by a hospital. We go for an office visit 8/1 visit is billed as a 99214 location being office a week later he has a stress test done at the same location and the office bills it as a hospital location the charges are $3,000 more then they were 3 years ago when he had the same test at the same location. I have many issues first not knowing they were bought, second how can you bill at the same location two different place of services. Does this sound correct?

  2. #2
    Location
    Dover Seacoast New Hampshire
    Posts
    2,028
    Default
    It is correct. Welcome to provider-based billing.

    When private practices are purchased by a hospital, there are two options. One is to keep the practice as just that-- a practice where the services are billed as office services. This happens most frequently if the hospital has an associated physician corporation; a group of practices under the umbrella of the hosptial, but a separate business.

    What you're describing is the second option, where the practice becomes a department of the hospital. Essentially, the practice now becomes an outpatient department (POS 22), and as such the 'practice' can bill both a professional fee and a technical fee, just as other outpatient services are billed (think about a visit to the emergency room...you get a hospital bill for the ED visit, and a bill for the ED physician's work).

    What's happened with your husband's cardiology practice is that you're getting a bill for the physician's E&M, provided in the outpatient setting, and you're getting a bill for the hospital's share of the overhead---as an outpatient department, the hospital can bill for their reimbursement of the cost of providing the service; nursing care and testing for example, just as they would for any other outpatient visit. It costs more because the hospital (being a facility) can get reimbursed more for diagnostics and procedures than if it was done in the office AND you still get to bill profesional and technical services for both.

    The physician's bill is submitted on a 1500 form and the outpatient hospital bill is submitted on the UB. There is occasionally more cost transferred to patients, as you've experienced, but it is legal, and becoming much more prevalent as private practices can no longer afford to stay independent.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3
    Location
    Columbia, MO
    Posts
    12,913
    Default
    so I guess the real question here is did they bill the visit level as pos 22 OR pos 11, then was the procedure billed as a POS 22 0r 11. You cannot mix up the POS. So if the visit was an 11 the procedure has to be an 11.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Location
    Bay City, Michigan
    Posts
    56
    Default
    Medicare wants hospital owned practices to notify them that your dept/office is a provider based location. Billing insurances and/or patients for out patient facility charges is a quick way to turn patients and insurances away from choosing your provider next time.
    collison3150

  5. Default
    Quote Originally Posted by Pam Brooks View Post
    It is correct. Welcome to provider-based billing.

    When private practices are purchased by a hospital, there are two options. One is to keep the practice as just that-- a practice where the services are billed as office services. This happens most frequently if the hospital has an associated physician corporation; a group of practices under the umbrella of the hosptial, but a separate business.

    What you're describing is the second option, where the practice becomes a department of the hospital. Essentially, the practice now becomes an outpatient department (POS 22), and as such the 'practice' can bill both a professional fee and a technical fee, just as other outpatient services are billed (think about a visit to the emergency room...you get a hospital bill for the ED visit, and a bill for the ED physician's work).

    What's happened with your husband's cardiology practice is that you're getting a bill for the physician's E&M, provided in the outpatient setting, and you're getting a bill for the hospital's share of the overhead---as an outpatient department, the hospital can bill for their reimbursement of the cost of providing the service; nursing care and testing for example, just as they would for any other outpatient visit. It costs more because the hospital (being a facility) can get reimbursed more for diagnostics and procedures than if it was done in the office AND you still get to bill profesional and technical services for both.

    The physician's bill is submitted on a 1500 form and the outpatient hospital bill is submitted on the UB. There is occasionally more cost transferred to patients, as you've experienced, but it is legal, and becoming much more prevalent as private practices can no longer afford to stay independent.
    Totally agree. I was welcomed to this world when I started working for my current employer. One visit for the price of two bills Now there are two reasons to be dissatisfied with your bill, one professional bill and one facility bill.

    Typically though, an office would notify you to expect two bills and about the changes. It's unfortunate that this didn't seem to happen in this scenario.

  6. Default
    Quote Originally Posted by mitchellde View Post
    so I guess the real question here is did they bill the visit level as pos 22 OR pos 11, then was the procedure billed as a POS 22 0r 11. You cannot mix up the POS. So if the visit was an 11 the procedure has to be an 11.
    Under provider based billing, the physician charges are on a HCFA 1500 with a pos of 22. The facility bills on a UB04 with a TOB 131. Both are equivalent to an outpatient place of service.

  7. #7
    Location
    Huntington, WV
    Posts
    14
    Default
    I am coding for an urgent care facility that is owned by the hospital. It has recently gone to provider based billing. However we are only coding provider based for Medicare currently and we are only charging the G0463 code on the facility side with everything else being billed on the provider side. I have been researching this and it seems that we should be charging more on the facility side. A patient will come in and receive multiple injection or intravenous drugs and we are not getting reimbursed for any of it. We are only able to recoup the money for the E&M charge and any procedures.

    My specific questions are these:
    1. Instead of billing (for example) a 96372 on the provider side, would I bill that to the facility side?
    And if so, does the G code receive a 25 modifier like a 99211-99215 would?

    2. When a procedure is completed, i.e. 12001, do I bill this on the facility and the physician sides?
    And if so, would I use the 25 modifier on each E&M code?

    3. Do I code an E&M code on both the facility and provider sides?

    Any information in this area would be extremely helpful!
    Also any documentation regarding this with examples would be greatly appreciated!

    Thanks in advance for any advice,

    Mariann Dalton

  8. #8
    Location
    Boise, Idaho
    Posts
    424
    Default
    Mariann,
    everything done in the office for the medicare patient would be split billed except for drugs. Those go on the facility claim only.
    x-rays, injections, e/m. all split billed.
    It is a requirement that the patient be notified of the change. Most places have them sign a form to that effect everytime they are seen. Some just have large signs set out.

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