Wiki Billing office visit for patient in rehab facility

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lmfort

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Patient is currently in a rehab facility and needs to be seen in our office (specialist). I'm seeing that we should bill our normal office visit code but use the rehab facility place of service. Is this correct?
Also, patient has United Healthcare Medicare. Would we bill this charge to UHC Medicare or regular Medicare?
Thanks in advance for your help!
 
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If the patient is to be seen at your office, outside of the facility, you will bill a normal E/M with the office place of service. The claim would go to his UHC plan. If you provide any other services outside of the E/M, You need to check the UHC contract. The facility may received global payment that included specific services. You may need to bill the facility for reimbursement. Nursing facilities have a similar contract with Medicare. Office visits are paid straight to the provider, then there is a list of other services the provider has to bill the facility for reimbursement. Hope this helps
 
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My understanding was that if the patient is currently in an approved inpt or rehab stay, the POS is to reflect the POS of the where the patient is registered and not necessarily where the patient was actually seen. While the E/M is an excluded service from the facility consolidated billing, you will receive facility reimbursement.
I do know for sonograms, you bill the professional component to insurance and the technical component to the facility.
 
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We are Specialists and see IP Rehab patients. We are having the same problem. If we bill out office em w/ office POS, the claim is denied . If we bill our office em with POS 61 (IP Rehab Facility) it is denied because the POS and EM don't go together. Medicare told us to appeal and it would be paid....nope, still denied. Wouldn't it be fraud to bill an i/p em code if that is not where the patient was seen? The patient came to our office.
Is there anything in writing on how to bill these office visits that do not pertain to the Provider being apart of the agreement with the IRF ?
 
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This has been my experience, as I too bill for a specialist (Ophthalmology) and we see many patients who are either in Rehab or SNFs: We never bill with the POS of the facility, as we are not seeing the patient in that facility. We will bill with POS 11 - the e/m denials you have may be payer-specific, so you may need to delve into their policies regarding that if it's an HMO type plan, but Medicare (Novitas is our MAC) will pay us for our e/ms (no mods). If we are performing tests (like an OCT 92134) we append modifier 26. We are adamant about getting service agreements from facilities regarding the non-coverage of services from the insurance before we see the patient. For example, we do a lot of intravitreal injections, which when the patient is utilizing their Medicare Part A benefits it falls under the consolidated billing rules - so Medicare will not pay us. We either have a service agreement with the facility to get reimbursed or we advise the patient of the non-coverage and have them pay us.

Sometimes we will get denials still, so then we have to prove the patient physically left the facility they were in to come see us, otherwise to the insurance if the patient is in an IP type stay why would they leave the facility? (Silly, I know lol) So we also tell the facility to provide us with either a transportation form, transfer of care form, or some documentation that shows the patient did leave and was seen by us. When we appeal with this documentation, usually get paid then.

Your situation could be vastly different from what I've described above, but I hope just the little bit of insight of what we do might help or give you some ideas! :)
 
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