Facility Guidelines for Claims Related to Professional Services - Facility
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Defines when professional services must be billed on a CMS-1500 versus a UB-04 for facility-related claims and describes applicable modifier and revenue-code billing rules for providers submitting outpatient and emergency services claims to the health plan.
Updated to not allow professional services under revenue codes 0920, 0929, and 0942 for reimbursement when submitted on a UB-04; updated Kentucky and Wisconsin exemption to allow reimbursement for revenue codes 0920, 0929, and 0942 when submitted on an UB-04.
Requires modifiers PN, PO, and ER to be appended to outpatient UB-04 claims when services are not billed on a CMS-1500, with PN reimbursed at 40% and PO/ER reimbursed at 100% of allowable as described.
Facility Professional Services Coverage
Facility professional services coverage criteria
Billing and reimbursement stance for professional services in facility settings:
Source: policy prohibition on professional services billed on UB-04.
ALL of the following
- Evaluation and Management services rendered in an office, professional building, medical office building, clinic, or a space owned or rented by a hospital or institutional provider (off-campus).
- Evaluation and Management services rendered within the primary structure of a facility.
- Preventive Counseling services rendered in an outpatient setting of a facility.
Modifier requirements
- Append modifier PN 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 allowable).
- Append modifier PO for services, procedures and/or surgeries provided at off-campus provider-based outpatient departments that are specifically contracted under the hospital agreement (PO reimbursed at 100% of allowable).
- Append modifier ER for outpatient hospital services furnished in an off-campus provider-based emergency department (ER reimbursed at 100% of allowable).
These revenue codes represent professional/diagnostic/therapeutic fees and are excluded on UB-04 submissions.
ER E/M reimbursement allowed under appropriate revenue codes; professional ER services still billed on CMS-1500.
General policy stance
High-level stance and limitations
Codes, Modifiers, and Billing Rules
| 99281-99285 | Emergency Room E/M codes |
| G0380-G0384 | Emergency Department visit HCPCS G-codes |
| PN | Modifier PN — Nonexcepted service provided at an off-campus outpatient provider-based department (reimbursed at 40%) |
| PO | Modifier PO — Excepted service provided at an off-campus outpatient provider-based department (reimbursed at 100%) |
| ER | Modifier ER — Items and services furnished by a provider-based off-campus emergency department (reimbursed at 100%) |
| 0920, 0929, 0942, 960-989 | Revenue codes identified as professional fees/diagnostic/therapeutic generally not allowed on UB-04 |
| No codes listed |
Provider Billing Requirements and Authorization
Authorization and medical necessity
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; providers must use proper billing and submission guidelines and ensure services billed with CPT, HCPCS, and/or revenue codes are fully supported in the medical record and/or office notes. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection, denial, or recovery/recoupment of payment.
- Bill services with industry-standard CPT, HCPCS, and/or revenue codes supported by medical records or office notes.
- Obtain any required prior authorizations and ensure medical necessity criteria are documented for the member’s state of residence.
- Noncompliance may lead to claim rejection, denial, or recovery/recoupment.
Policy use and updates
The payer reserves the right to review and revise reimbursement policies periodically; the policy is subject to applicable federal and state laws and the terms, conditions, and limitations of a member's benefits on the date of service. When policies are updated, the most current policy will be published to the website.
- Reimbursement Policy may be superseded by federal, state, or CMS mandates or provider contract requirements.
- Policy updates may be implemented retroactively to the effective date and the payer reserves the right to recoup or recover payments in accordance with the policy.
Key Terms
Policy Updates & Effective Dates
Policy review approved reflecting updates to reimbursement rules and state exemptions; changes include disallowing professional services under revenue codes 0920, 0929, and 0942 on UB-04 and updating Kentucky and Wisconsin exemptions to allow those revenue codes on UB-04.
Revised policy effective date for the updated reimbursement and exemption rules (disallowing revenue codes 0920, 0929, 0942 on UB-04 generally; Kentucky and Wisconsin exemptions updated to allow those codes on UB-04).
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