Facility Guidelines for Claims Related to Professional Services - Facility
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Governs how professional services should be billed (CMS-1500 vs UB-04) for facility-related outpatient and emergency services for Blue Cross Blue Shield - Nevada commercial lines and specifies when facility claim modifiers apply.
Modifiers PN, PO, and ER must be appended on outpatient UB-04 claim lines when services are not billed on a CMS-1500, with specific meanings for off-campus non-contracted, off-campus contracted, and off-campus emergency department services.
Updated Definitions by adding 'Provider-based off-campus emergency department'.
Revenue codes 960-989 (professional fees) are not allowed for reimbursement when submitted on a UB-04; such services should be billed on a CMS-1500 with applicable HCPCS/CPT codes.
Billing and Reimbursement Criteria
Billing and reimbursement criteria
Claims and billing requirements for professional services related to facilities:
ALL of the following
- Evaluation and Management services rendered in an office, professional building, medical office building, clinic or a space owned by a hospital or an institutional provider, other than the primary structure on the campus of the hospital or institutional provider, or rented by a professional from the hospital or an institutional provider.
- Evaluation and Management services rendered within a primary structure of a facility.
- Preventive Counseling services rendered in an outpatient setting of a facility.
ALL of the following
- Modifier PN — must be appended for services, procedures and/or surgeries provided at an off‑campus location that is not contracted as part of the hospital agreement (PN reimbursed at 40% of the allowable).
- Modifier PO — must be appended for services, procedures and/or surgeries provided at any off‑campus provider‑based outpatient departments that are specifically contracted under the hospital agreement.
- Modifier ER — must be appended for outpatient hospital services furnished in an off‑campus provider‑based emergency department.
Key Codes and Revenue Guidance
| 99281-99285 | Emergency Room Evaluation and Management codes (reimbursed when billed under the appropriate revenue codes) |
| G0380 | ER visit code (reimbursed when billed under the appropriate revenue codes) |
| G0384 | ER visit code (reimbursed when billed under the appropriate revenue codes) |
| PN | Nonexcepted service provided at an off-campus, outpatient, provider-based department of a hospital; reimbursed at 40% of the allowable |
| PO | Excepted service provided at an off-campus, outpatient, provider-based department of a hospital |
| ER | Items and services furnished by a provider-based, off-campus emergency department |
Required Billing Submission Actions
Billing submission actions — use CMS-1500 for professional services; append PN/PO/ER if on UB-04
Do not bill professional services on a UB-04 claim form unless provider, state, federal contracts and/or mandates indicate otherwise. Evaluation and Management services (as listed) and preventive counseling rendered in outpatient facility settings must be billed on a CMS-1500. If professional services are submitted on a UB-04 outpatient claim instead of CMS-1500, append modifier PN for off-campus non-contracted provider-based departments, PO for off-campus contracted provider-based outpatient departments, or ER for off-campus provider-based emergency department services on each applicable claim line.
- Bill E/M services rendered in office, professional building, clinic, or space owned/rented by a hospital on CMS-1500.
- Bill E/M services rendered within the primary structure of a facility on CMS-1500.
- Bill preventive counseling services rendered in an outpatient facility setting on CMS-1500.
- If billing these professional services on UB-04, append PN, PO, or ER as defined for each claim line.
Key Definitions
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