# Facility ESI Billing-We have an



## dgarrett10 (Jan 23, 2016)

We have an independent  CRNA performing ESI's at our facility.  The referring provider has been getting precerts and the facility is billing under the referring provider with his precert for facility charges.  Should the facility be billing facility charges under the rendering provider which is the CRNA and this would mean that the precert is no good because the rendering provider did not get the precert.  Please give me directions to get proof for how this should be billed.  I believe the rendering provider would be on the claim not the referring provider who is an Orthopedic surgeon.  Any suggestions??


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## dwaldman (Jan 24, 2016)

Below describes that the incident to benefit does not apply in the facility setting if a mid level provider provides a service solely by themselves then that service is billed under their NPI from a Medicare perspective. A private payer might have certain instructions where they would request a service to be billed under the supervising provider, but that would require specific instructions from that carrier requesting that and that would not be a guideline of Medicare. When you describe the epidural being billed under the Orthopedic doctor, are you describing a situation where the ortho doctor is performing a surgery and his office is getting an authorization for a epidural for the patient in addition to his surgery codes? If this is the case, yes the ortho doctor would be the attending and operating surgeon on the claim, but the CRNA with their NPI can also be listed since they performed a distinct service, the above response is considering this epidural is in conjunction with a surgery on the same day. I am assuming this is not for epidurals in a pain clinic setting at the hospital. 

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http://www.wpsmedicare.com/j5macpar...-providers-incident-to-guidelines-pos22.shtml

Mid-Level Providers, Incident To Guidelines and POS 22

WPS Medicare recently conducted a teleconference specific for mid-level providers. This includes Nurse Practitioners, Physician Assistants, Clinical Nurse Specialists and Clinical Nurse Midwives. One situation discussed was provider-based billing. When the hospital also bills a facility fee for the service, the correct place of service (POS) for the physician or mid-level billing is POS 22.

Incident to service guidelines do not apply to those items billed in POS 22. Therefore, a mid-level provider seeing a patient must bill under his/her own National Provider Identifier (NPI). In POS 22, in order to bill under the physician's provider number either the physician has performed the service or the situation meets the shared/split guidelines. The shared/split guidelines indicate both the MD/DO and the mid-level provider are in the same group (meaning under the same tax id) and both are providing a portion of the service to the patient. The guidelines are in the Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.1.B.

Physicians who have billed for services provided by the mid-level provider in POS 22 when the shared/split guidelines did not apply should refund Medicare the difference in payment. Physicians are allowed at 100% of the Medicare Fee Schedule and mid-level providers are allowed at 85%. We have instructions on our Payment Recovery web page concerning refunding Medicare.

If you have large numbers of payments to return, you can contact our Payment Recovery telephone analysts at (866) 503-9694 for more information.


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## dgarrett10 (Jan 25, 2016)

*ESI's*

This is for pain clinic in outpatient setting for CRNA.


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## dwaldman (Jan 27, 2016)

I would ensure that the CRNA is credentialed by the facility to perform epidurals and a CRNA in the state you are in are allowed to performed epidurals. I would believe that the providers office and your manager and the facilities compliance officer need to review the reason they getting the auth under the physician when there sounds like there is prior knowledge that the CRNA will be schedule to perform the service. I would believe there are certain carriers that are not going to authorize a CRNA to perform routine epidurals in a pain clinic. I would also discuss with management and the compliance officer at the facility, if it is correct coding practices that the CRNAs name and NPI is not the hospital claim. 

I don't think it is about saying there has to be references that define this for us. It just takes meeting with everyone and discussing: why is the auth not being done under the CRNA, does the carrier that is being billed cover CRNAs performing epidurals in pain clinics, has anyone requested the authorization personell to get the auth under the CRNA if that is the one is going to perform the service so the facility claim can match who is performing the service. Is Medicare being billed on the facility claim under the "referring provider" instead of the CRNA because this would be incorrect coding and a correct claim needs to be filed.

I would get the compliance officer at your facility involved ASAP.


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