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Hospital Owned Physicians office

  1. #11
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    Medical Coding Books
    I am currently facing a similar situation with a 1206B clinic, where the clinic is a hospital based clinic, the staff is employed by the hospital but the doctors are not considered hospital employees. The doctors bill for their "professional" E/M services and the hospital bills for the facility. My question is, and I have gotten contradicting info on this before, if the doctor bills for example a 99213 using 22 as the POS, shouldn't the hospital also bill for a 99213? or should the hospital bill using a different E/M code? A question was asked as to where to obtain more info on this subject but I did not see a response, can someone enlighten me as well? Thanks

  2. #12
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    The facility E&M will be whatever level is met according to the facility criteria, it might equal the physicians level but it might not. Facilities do not follow the same criteria as the physician for the E&M and each facility is different as they are required to make up their own. So it will be only a coinicidence if your levels match.

    Debra A. Mitchell, MSPH, CPC-H

  3. #13
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    I was actually told that each facility makes up their own, but I really found that so hard to beleive. Where can I get information regarding what criteria to follow, benchmarks etc. And if facilities create their own what would CMS use to audit them, their own criteria? I guess I'm finding it hard to beleive that CMS will leave this decesion up to the facilities. Is there a website or other source where I can get more info and actually have something to show? I'm suppose to attend a meeting this afternoon and any info would be greatly appreciated. Thanks.

  4. #14
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    Columbia, MO
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    Quote Originally Posted by medsolutions View Post
    I was actually told that each facility makes up their own, but I really found that so hard to beleive. Where can I get information regarding what criteria to follow, benchmarks etc. And if facilities create their own what would CMS use to audit them, their own criteria? I guess I'm finding it hard to beleive that CMS will leave this decesion up to the facilities. Is there a website or other source where I can get more info and actually have something to show? I'm suppose to attend a meeting this afternoon and any info would be greatly appreciated. Thanks.
    I understand you skepticism but it has been that way since 2000. This is due to OPPS and APCs Outpatient prospective payment system (OPPS) and ambulatory procedure classifications (APCs). Hospitals had to have a way to capture the facility charge using a CPT code so that it could be placed into an APC for payment. No such codes existed and no guidelines exisited. Therefor CMS directed the facility to utilize the E&M codes, however the guidelines were created for physician use, and the facilities now had to capture their utilization of resources, so CMS instructed that the facilities were to create their own unique criteria to determine the E&M level, there are certain requirements this criteria must follow but beyond that it can be whatever the facility desires. So for example we used a point system so to have vitals signs taken was 5 points, and if we wanted to we could say that a 99211 was equal to 5 points and so on. Look up OPPS and APCs the instructions are there as well as the dos and don'ts.

    Debra A. Mitchell, MSPH, CPC-H

  5. #15
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    Thank you so much, that really helps.

  6. #16
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    O.k., I may be asking for much, but I went onto cms.gov and can not find anything that has to do with the dos and dont's you are referring to, do you have a link or is there somethng more specific I need to put in the search field to get this info? I'm sorry to keep bugging you, but I've been trying to get this info for over a week now, and I'm very frustrated. Thanks.

  7. #17
    Location
    Columbia, MO
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    I am not sure where you can find this on the CMS web my link for.this is ages old. Try a Google search for opps or apc or even facility e&m billing. I worked in the outpatient area in 2000 and did all the leg work on APC coding at that time. I even taught a seminar on APCs for a couple of years. So I know you will find it, just may take some digging.

    Debra A. Mitchell, MSPH, CPC-H

  8. #18
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    Thank you for your help, I really appreciate it.

  9. #19
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    Hi,
    Can someone please tell me whether it makes a difference if it is a separate physician group vs. an employed physician by the hospital? In either case can we still bill for both, professional fees and facility fees?

    Thanks so much!

  10. #20
    Default Physician based office
    Are these regulations apply to inpatent long term facility clinic billing?

    Contracted cardiologist seeing a registered inpatents in long term psych facility
    . Hospital owns the office, paying for an employees and paying a cardiologist a contracted dollar amount. Doctor wants to use the POS as 11.

    What will be the correct POS in this setting?


    Thank you for your help.
    Mariam Gabrielian, CPC

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