Wiki Separate provider performing an outpatient procedure on an inpatient client

[lburns23]

We are a pain management clinic that offers EMG/NCS. We have a relatively new relationship with an inpatient rehabilitation hospital - last year they sent us a referral for one of their patients who needed an EMG so she was brought to our clinic and the study was performed here. I didn't know at the time that I couldn't bill Medicare - so I billed them, they paid, and then they recouped. I sent the claim to the rehab hospital and they paid on the technical component portion only of the EMG/NCS. They told me I could still bill Medicare for the office visit and perhaps the professional component; I've been trying to research how to do this and just can't find anything that's straightforward enough.

The doctor who performs the EMG doesn't like the idea of just getting the data and sending a bunch of charts, graphs, and numbers for them to interpret. He wants to do both the technical and professional component. The office visit (consult) portion is negotiable but he also really likes getting their history and co-morbidities and such to determine the most appropriate diagnosis in conjunction with the test results.

I cannot figure out how to bill our claim to get the rest of it paid. I tried several methods to bill Medicare with no success. Do we use our place of service code (11) with a modifier (like you'd use GW for a hospice patient seen in the ER) or theirs (21) but then would I put our service location or their address (and NPI)? I am the only biller/coder and don't have anyone to ask these questions to - my emails and phone calls to the inpatient hospital have gone unanswered. For the most part I have trial-and-error'ed my way to learning all the ins and outs of my job, but I'd appreciate some advice on this one! We have a new referral that we'd like to accept but only if we know we're going to be paid reasonably for the amount of time and effort it takes for these patients.

 

[SharonCollachi]

Your doctor sounds like my doctor - he wants to do it all. He sees patients at an inpatient rehab hospital, and we were talking recently about services a patient needed that could only be provided at a specific doctor's office (it was an expensive drug that the patient needed). Since the patient was inpatient, the rehab hospital was responsible for all services, including medications. If the patient was outpatient, he could have gone to that doctor's office and gotten the injection and the doctor could have billed for it; since he was still inpatient that doctor could not bill, and the hospital knew they would be eating the cost.

Since they are hiring you for the test, there is no separate office visit. Their doctor already decided the patient needed the test; they just didn't have the equipment at the hospital. I would bill the hospital for the technical portion of the test, and bill Medicare for the professional component of the test (modifier 26).

If your doctor went to the hospital, you would bill POS 61 (unless it was Medicaid, then it would be POS 21 with modifier U2 - at least, it would in California).

If the patient came to you, I believe you would bill the POS as 11 (although I'm not positive on that - looking for someone else to chime in).

 

[lburns23]

Your doctor sounds like my doctor - he wants to do it all. He sees patients at an inpatient rehab hospital, and we were talking recently about services a patient needed that could only be provided at a specific doctor's office (it was an expensive drug that the patient needed). Since the patient was inpatient, the rehab hospital was responsible for all services, including medications. If the patient was outpatient, he could have gone to that doctor's office and gotten the injection and the doctor could have billed for it; since he was still inpatient that doctor could not bill, and the hospital knew they would be eating the cost.

Since they are hiring you for the test, there is no separate office visit. Their doctor already decided the patient needed the test; they just didn't have the equipment at the hospital. I would bill the hospital for the technical portion of the test, and bill Medicare for the professional component of the test (modifier 26).

If your doctor went to the hospital, you would bill POS 61 (unless it was Medicaid, then it would be POS 21 with modifier U2 - at least, it would in California).

If the patient came to you, I believe you would bill the POS as 11 (although I'm not positive on that - looking for someone else to chime in).

Thank you so much for your input!!