Wiki Facility Billing vs Hospital billing

[encomma-watson]

I have been pondering this question for months now. We have some auditors on site, and they are questioning why we are not billing hospital charges. I have been told that we can bill (2) 99214 - one with 99214 TC modifier and the other 99214 26. I have been coding for a long time and I know that TC is a technical component (which is used for radiology studies and 26 is the profession component modifier which goes with radiology) Am I correct in asking this question? Our providers do not see the patient in the hospital, but when the patient is discharged and coming to our office for hospital follow up, management was told to use TC and 26.

 

[sls314]

I have been pondering this question for months now. We have some auditors on site, and they are questioning why we are not billing hospital charges. I have been told that we can bill (2) 99214 - one with 99214 TC modifier and the other 99214 26. I have been coding for a long time and I know that TC is a technical component (which is used for radiology studies and 26 is the profession component modifier which goes with radiology) Am I correct in asking this question? Our providers do not see the patient in the hospital, but when the patient is discharged and coming to our office for hospital follow up, management was told to use TC and 26.

Well that's...interesting...advice

Yes, there is such a thing as facility and non-facility rates for E/M codes. But that's not based on TC/26 billing.

When a physician bills 99214 with POS 11, they will be reimbursed the non-facility rate. This accounts for both the physician's time and overhead.

Sometimes a physician's office is located within a facility, and the physician & the facility each bill for their share of the visit. The physician would bill the 99214 with POS 22 and be reimbursed for the physician's time. The hospital would bill with Revenue Code 510 w/99214 and be reimbursed for the overhead.

 

[encomma-watson]

Well that's...interesting...advice

Yes, there is such a thing as facility and non-facility rates for E/M codes. But that's not based on TC/26 billing.

When a physician bills 99214 with POS 11, they will be reimbursed the non-facility rate. This accounts for both the physician's time and overhead.

Sometimes a physician's office is located within a facility, and the physician & the facility each bill for their share of the visit. The physician would bill the 99214 with POS 22 and be reimbursed for the physician's time. The hospital would bill with Revenue Code 510 w/99214 and be reimbursed for the overhead.

That makes a lot of sense now. So then, because we are on EPIC, would I still bill 99214-22 modifier with POS 11, then would I bill 99214 and no modifier?

 

[thomas7331]

That makes a lot of sense now. So then, because we are on EPIC, would I still bill 99214-22 modifier with POS 11, then would I bill 99214 and no modifier?

Why would you bill with modifier 22? Being on EPIC should have no impact on your coding. If you’re a private practice, then you bill your E/M codes with POS 11. If it’s a practice owned by a hospital with provider based status, you bill the same code but with POS 19 or 22 and the hospital portion is billed separately on the UB claim.

Hospital charges for E/M visits are billed with HCPCS code G0463 to Medicare, or with regular E/M CPT codes to commercial payers who accept them. Levels for the hospital charge may not always match what the physician bills because the criteria are different.

 

[amyjph]

This is not making a lot of sense. Are you sure you are understanding the question or the advice you are being given from the folks you say are on site? I think there may be more to this than we are seeing here. Modifiers and place of service are two totally different things. And, if an auditor is really saying what you stated above it really makes zero sense. Agree, Epic has nothing to do with what is being coded.
Then, you are stating, "Our providers do not see the patient in the hospital" So, if the provider is private office based it's POS 11 and facility/hospital billing doesn't come into play at all. Or, like Thomas advised above iof the hospital owns.

I would wonder how one came to find themselves in an auditing position if they are advising someone to put a TC & 26 on an E/M...

 

[encomma-watson]

This is not making a lot of sense. Are you sure you are understanding the question or the advice you are being given from the folks you say are on site? I think there may be more to this than we are seeing here. Modifiers and place of service are two totally different things. And, if an auditor is really saying what you stated above it really makes zero sense. Agree, Epic has nothing to do with what is being coded.
Then, you are stating, "Our providers do not see the patient in the hospital" So, if the provider is private office based it's POS 11 and facility/hospital billing doesn't come into play at all. Or, like Thomas advised above if the hospital owns.

I would wonder how one came to find themselves in an auditing position if they are advising someone to put a TC & 26 on an E/M...

I have been fighting with the Professional Billing Manager @ the healthcare system and I told her that TC & 26 modifiers are used for radiology, but she is insisting that I can use that for duplicating (i,e) 99213 or 99214. I am supposed to be doing split billing using the modifiers TC & 26.

The problem is that I have four different sites and the one site I am working claims review is an outpatient hospital facility. I have never worked outpatient hospital facility before so of course this is very confusing for me. So now the Intermediate Accountant for Ambulatory Services is asking why did we stopped billing hospital billing visits. (Again, our providers do not see the patients in the hospital, we see the patient's that comes out of the hospital for hospital follow-ups. These patients might not have a PCP, which means that now they become our patients. I hope this all kind of make sense to you all that are helping me.

 

[encomma-watson]

Why would you bill with modifier 22? Being on EPIC should have no impact on your coding. If you’re a private practice, then you bill your E/M codes with POS 11. If it’s a practice owned by a hospital with provider based status, you bill the same code but with POS 19 or 22 and the hospital portion is billed separately on the UB claim.

Hospital charges for E/M visits are billed with HCPCS code G0463 to Medicare, or with regular E/M CPT codes to commercial payers who accept them. Levels for the hospital charge may not always match what the physician bills because the criteria are different.

I have been fighting with the Professional Billing Manager @ the healthcare system and I told her that TC & 26 modifiers are used for radiology, but she is insisting that I can use that for duplicating (i,e) 99213 or 99214. I am supposed to be doing split billing using the modifiers TC & 26.

The problem is that I have four different sites and the one site I am working claims review is an outpatient hospital facility. I have never worked outpatient hospital facility before so of course this is very confusing for me. So now the Intermediate Accountant for Ambulatory Services is asking why did we stopped billing hospital billing visits. (Again, our providers do not see the patients in the hospital, we see the patient's that comes out of the hospital for hospital follow-ups. These patients might not have a PCP, which means that now they become our patients. I hope this all kind of make sense to you all that are helping me.

 

[amyjph]

This sounds like a big miscommunication and mix up with HB vs. PB and how charges are entered/billed in the internal system. It really seems like a huddle or meeting may be needed for you with all involved. Or, if you have a lead, supervisor or manager that can give direction it seems like you need help. I am not sure the folks on this forum can really assist with this other than giving the basic coding rules and guidance from a regulatory and coding perspective.
There may be some internal or some other reason they are telling you this. Do they use the 26 and TC as some internal code to tell the system to split it even though it may not pass through onto a claim? It all sounds odd to me.

Susan's info in her last sentence above is I think what you might be talking about. UB vs. CMS 1500 billing.

 

[thomas7331]

I agree with Amy here. Sometimes you just have to work through things with your organization’s leadership. If you bill TC and 26 modifiers on E/M codes, that’s incorrect and is going to cause denials, but it’s possible that you may need to enter these modifiers into the billing system to trigger the system to bill correctly and that the modifiers won’t actually go onto the claims. But that’s something that your employer would need to advise you about - no one on the forum here is going to understand how your system is configured. But if the office or site that you’re coding for is part of the hospital and/or has provider-based status, then yes, you would need to be billing both a professional and a facility claim.

 

[encomma-watson]

Thank you for everyone who answered my question to clarify everything. I will be using G0463 from now on and see if will make the powers that be happy.