Wiki PHYSICIAN E&M SERVICE AND FACILITY INFUSION ON THE SAME DAY

[Rupa Lalai]

Physician E&M service and facility infusion on the same day-

In multiple sclerosis clinic, often times, the physician ends up seeing the patient on the same day as infusion therapy that is billed by the facility. (J2350 and J2323)

Since the clinic and infusion suite is hospital owned, there is conflict on how the physician services should be billed.

Following CPT guidelines if there is a significant and separate identifiable E&M it should be billable.

However, since both the infusion suite and physician clinic is hospital based/owned would the POS be 22?.

I know the facility is reporting an E&M + infusion codes, but would the physician E&M also be billed? If so, is it with modifier 25 or w/o? If not, is it because there is already an E&M code the facility is billing? Can J codes be billed under physician services? Also which E&M codes would the facility be reporting? What would be the place of service for physician E&M service?

Thanks

 

[thomas7331]

If the clinic is part of the hospital, then the facility will bill all of the technical services - the infusion, drugs, and also the facility portion of the E&M service with a modifier 25, if supported, for the use of the clinic space and staff time. For Medicare, hospitals now bill G0463 for the E&M service, but some commercial payers may still want the physician outpatient E&M CPT code on the facility claim. The physician will only bill the professional service which in this case would be the E&M CPT code, using place of service 19 or 22, depending on the whether the clinic is on-campus or off-campus.

Facility and physician claims don't overlap at all, so there would be no need for a modifier 25 on the physician claim if that is the only professional service billed by the physician for the patient on that date.

 

[Rupa Lalai]

Thanks