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E/M Billed by both ED Physician and Hospital?

  1. Default E/M Billed by both ED Physician and Hospital?
    Medical Coding Books
    Hi there,

    I am sorting through EOBs and see that a patient was charged an emergency department E/M by the Ed physician AND by the hospital. Two different levels, same 5-hour visit, both ED E/M codes. I wasn't aware that the hospital could charge for the E/M when a contracted physician provided the service and billed separately...

    Any clarification would be greatly appreciated. If you could point me in a direction to get data to fight with the hospital (if that's what I need to do), I would also appreciate it.

    Karen Scott, CPC, CPC-I
    Pierce College at Puyallup

  2. #2
    Dover Seacoast New Hampshire
    Remember, the physician bills for their service (E&M) and the facility bills an E&M (not based on key components...based on resources used, but reported using the 992xx codes) in order to be reimbursed for the overhead. The hopital has to be paid also....they don't let the physicians do their business in the ED for free. That's how they pay the nurses, for the equipment, the lights and phones, the maintenance.

    If the physician is contracted, even as an employed physician-- they are entitled to their pro-fee reimbursement. Now if the hospital is billing the pro-fee on behalf of the physician, and the physician is also billing the pro-fee on behalf of himself, that's another story--it's double billing. But it appears by your post that the hosptial is billing a pro fee and a technical fee for the emergency visit. Yep, that's how it's done.
    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. Default Any references
    Hi Do you have any references for this information?
    I need to find something to refer to when auditing.


  4. #4
    Columbia, MO
    Just google up APCs and OPPS for hospital outpatient. There is a ton of information on this and it is nothing new. This started Aug of 2000.

    Debra A. Mitchell, MSPH, CPC-H

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