Wiki Facility Billing

[isa709@yahoo.com]

Hi everyone!!
I'm completely new to Facility billing so please understand my most honest confusion.
We have a group of Doctors/Surgeons that work for us, we own/have an ASC. They are currently billing the Facility fees and billing the Professional fee separately (2 separate claims, same CPT code). However they are not adding the MOD TC/26 to either of the claims. Medicare is paying the full fee for the Physician charge, denying the Facility charge (duplicate). My question would be:
Shouldn't we add the MODs to the claims?
or
Since we own the ASC and we are the ones paying the Physician (he works for us), Should we just bill one charge/claim (Global fee)?

Any clarification would mean the world!!!

Thank you.

 

[thomas7331]

If you're talking about an ASC, then I'm going to assume you're billing surgical CPT codes. If that's the case, there is no technical/professional component breakdown to these codes so you cannot submit modifiers TC or 26 as those are not valid for surgical codes. If you are talking about radiology or pathology codes, that's a bit of a different question though.

There should be no overlap between the facility and physician fees for a surgery - the ASC will bill the same surgical CPT and be paid the facility's rate, and the physician should bill it with a POS code 24 which will reimburse the physician at the rate that takes into account that it was done in a facility.

If you are getting a duplicate denial from Medicare, it sounds to me like you may be either billing the POS incorrectly on the physician claim, or else are using incorrect provider information or have a credentialing issue on the facility claim. The ASC, even if owned by the physicians, must separately licensed and be set up with its own NPI number and credentialed with Medicare as a facility, and if so, Medicare should recognize that as a facility and not consider it a duplicate of the physician's claim. If you are just billing a facility fee under the physicians' NPI numbers, then that could be why you are getting the denials.

 

[isa709@yahoo.com]

If you're talking about an ASC, then I'm going to assume you're billing surgical CPT codes. If that's the case, there is no technical/professional component breakdown to these codes so you cannot submit modifiers TC or 26 as those are not valid for surgical codes. If you are talking about radiology or pathology codes, that's a bit of a different question though.

There should be no overlap between the facility and physician fees for a surgery - the ASC will bill the same surgical CPT and be paid the facility's rate, and the physician should bill it with a POS code 24 which will reimburse the physician at the rate that takes into account that it was done in a facility.

If you are getting a duplicate denial from Medicare, it sounds to me like you may be either billing the POS incorrectly on the physician claim, or else are using incorrect provider information or have a credentialing issue on the facility claim. The ASC, even if owned by the physicians, must separately licensed and be set up with its own NPI number and credentialed with Medicare as a facility, and if so, Medicare should recognize that as a facility and not consider it a duplicate of the physician's claim. If you are just billing a facility fee under the physicians' NPI numbers, then that could be why you are getting the denials.

Thank you so much for your response!!!
Yes we are billing surgical procedures. We are using different NPI numbers for the facility and for the Physicians. There are 2 claims being submitted, one under the Facility NPI number same CPT as the other claim with the Physicians NPI number. Medicare is denying the Facility claim stating is a duplicate claim? Since I have no experience in Facility billing nor when to use MOD for them, I do not understand the duplication statement... Thank you again for your help!

 

[SharonCollachi]

Thank you so much for your response!!!
Yes we are billing surgical procedures. We are using different NPI numbers for the facility and for the Physicians. There are 2 claims being submitted, one under the Facility NPI number same CPT as the other claim with the Physicians NPI number. Medicare is denying the Facility claim stating is a duplicate claim? Since I have no experience in Facility billing nor when to use MOD for them, I do not understand the duplication statement... Thank you again for your help!

Your ASC should have a different Tax ID number than the physican/physician group doing the billing.

 

[thomas7331]

Thank you so much for your response!!!
Yes we are billing surgical procedures. We are using different NPI numbers for the facility and for the Physicians. There are 2 claims being submitted, one under the Facility NPI number same CPT as the other claim with the Physicians NPI number. Medicare is denying the Facility claim stating is a duplicate claim? Since I have no experience in Facility billing nor when to use MOD for them, I do not understand the duplication statement... Thank you again for your help!

It does not sound like a modifier issue - more likely it is the credentials you are submitting on the facility claim. I'd suggest talking with someone at your Medicare contractor about the claims that are denied and try to find out where the error is.

 

[isa709@yahoo.com]

Your ASC should have a different Tax ID number than the physican/physician group doing the billing.

Will definitely check!!! thank you

 

[isa709@yahoo.com]

It does not sound like a modifier issue - more likely it is the credentials you are submitting on the facility claim. I'd suggest talking with someone at your Medicare contractor about the claims that are denied and try to find out where the error is.

Absolutely! thank you!

 

[Amela_91]

Thank you so much for your response!!!
Yes we are billing surgical procedures. We are using different NPI numbers for the facility and for the Physicians. There are 2 claims being submitted, one under the Facility NPI number same CPT as the other claim with the Physicians NPI number. Medicare is denying the Facility claim stating is a duplicate claim? Since I have no experience in Facility billing nor when to use MOD for them, I do not understand the duplication statement... Thank you again for your help!

Hi, was there ever a resolution to this? I am having the EXACT same problem and have spent months trying to figure this out still with no answers on how to get our ASC claims paid.

 

[thomas7331]

Hi, was there ever a resolution to this? I am having the EXACT same problem and have spent months trying to figure this out still with no answers on how to get our ASC claims paid.

Have you spoken with Medicare about the denials and if so, what are they telling you? Any time a duplicate denial is issued, they will have a reference claim on file showing where the original payment determination was made, so that should give you a starting point in finding out the status of the original claim and understanding why it's a duplicate in Medicare's system but not in yours. Sometime a payment may have been misrouted or processed under an incorrect provider and you made need to track that down. But Medicare should be helping you through this process. Escalate the issue to a higher level representative at Medicare if you aren't getting the answers you need.