Facility Guidelines for Claims Related to Professional Services - Facility
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Defines when professional services must be billed on a CMS-1500 vs UB-04 and requirements for outpatient claim modifiers for off-campus provider-based services; applies to providers submitting claims to Empire Bluecross.
Revenue codes 0920, 0929, 0942, and 960-989 are not allowed for reimbursement when submitted on a UB-04 and professional services should be billed on a CMS-1500.
Modifiers PN, PO, and ER must be appended on outpatient claim lines when services are not billed on a CMS-1500, with PN reimbursed at 40% and PO/ER at 100% of the allowable.
Billing and Reimbursement Criteria
Billing and reimbursement criteria for professional services
Covered when ALL of the following are met:
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 must be billed on a CMS-1500 claim form.
- Evaluation and Management services rendered within a primary structure of a facility must be billed on a CMS-1500 claim form.
- Preventive Counseling services rendered in an outpatient setting of a facility must be billed on a CMS-1500 claim form.
- Services provided outside of a hospital's main campus that the health plan considers an office place of service shall not be billed or reimbursed on a UB-04 and must be billed on a CMS-1500 by the provider rendering the service.
- Revenue codes 0920, 0929, 0942, and 960-989 are not allowed for reimbursement when submitted on a UB-04 and professional services should be billed on a CMS-1500 with the applicable HCPCS/CPT codes.
- Emergency Room E&M codes (99281-99285, G0380-G0384) will be reimbursed when billed under the appropriate revenue codes; however, professional services for the Emergency Room must be billed on a CMS-1500 claim form.
- When services are not billed on a CMS-1500 and are reported on an outpatient claim, append modifier PN for non-contracted off-campus provider-based departments (PN), PO for off-campus provider-based outpatient departments contracted under the hospital agreement (PO), and ER for outpatient services furnished in an off-campus provider-based emergency department (ER).
Revenue, E/M, and Modifier Guidance
| 0920 | Other diagnostic services/general (not reimbursable on UB-04 for professional services) |
| 0929 | Other diagnostic services/other (not reimbursable on UB-04 for professional services) |
| 0942 | Other therapeutic services/education and training (not reimbursable on UB-04 for professional services) |
| 960-989 | Professional fees (not reimbursable on UB-04 for professional services) |
| 99281-99285 | Emergency Room E&M codes (reimbursed when billed under appropriate revenue codes) |
| G0380-G0384 | Emergency Room E&M HCPCS codes (reimbursed when billed under appropriate revenue codes) |
| PN | Append for services at an off-campus location not contracted as part of the hospital agreement (reimbursed at 40% per policy change notes) |
| PO | Append for services at an off-campus provider-based outpatient department contracted under the hospital agreement (reimbursed at 100% per policy change notes) |
| ER | Append for outpatient hospital services furnished in an off-campus provider-based emergency department (reimbursed at 100% per policy change notes) |
Authorization, Medical Necessity, and Operational Actions
Confirm authorization, medical necessity, and documentation before billing
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and the member's state of residence; failure to follow these requirements may result in claim rejection, denial, or recoupment. Use industry-standard CPT, HCPCS, and revenue codes and ensure services billed are fully supported in the medical record or office notes.
- Noncompliance may lead to claim rejection, denial, or recovery/recoupment of payment.
- All billed services must be supported in the medical record and use proper CPT/HCPCS/revenue codes.
Term Definitions
Facility / Admission Criteria
Facility
Facility-related billing rule:
ALL of the following
- Services provided outside of a hospital's main campus that the health plan considers an office place of service shall not be billed or reimbursed on a UB-04 claim form.
- These services must be billed on a CMS-1500 by the provider rendering the service.
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