Is the inserting RN an employee of the office or clinic? If so, there should be a bill for the insertion by the facility, however no professional fee should be billed. Professional fees are what the MD, NP or PA can bill but only for the procedures they actually perform. If the inserting RN is a contractor doing the insertion, he/she sends a bill for the insertion service to the office/clinic. This bill should be based on a prearranged contract between the inserting RN and the office/clinic. Again, the office/clinic can bill for the insertion but no professional fees can be billed by the MD. Someone please correct me if I am wrong on this, however my understanding has always been that the MD, NP, or PA can only bill professional fees directly to Medicare, private insurers, etc. for services they directly perform. Lynn
This is for a contracted service with the insertion being billed to the office/clinic. I am trying to figure out how the office could bill payors and maximize reimbursement. Looking at the document published by Cook Medical "2012 Coding and Reimbursement Guide" (http://www.cookmedical.com/ir/content/mmedia/IR-BM-CPPPCR-EN-201203.pdf), I am trying to figure out how the CPT codes for outpatient insertions could work in a private office or infusion center.
CPT codes are specifically used for those outpatient settings, so that is what is used for all procedures. There are 2 different types of billing - the facility/hospital/clinic bills for the procedure and the professional billing for a procedure which is ONLY open to MD, NP, and PA. The MD, NP or PA must do the actual procedure in order for them to bill a professional fee. The office/clinic bills the regular fee without adding the professional fee. If they do add the professional fee when someone else has actually performed the procedure, that could be regarded insurance fraud!! Lynn
Look closely at that Cook list. Notice the footnote of 1, 2, 3 by the columns with $$. There is a facility fee column and the one with a footnote of 3 is a professional fee. When a contracted service places the PICC, the facility can be billed. The professional fee can not be billed. Lynn
Our billing dept added the ultrasound code to the PICC code since all are placed via realtime US. That would not be considered a professional fee would it?
My understanding of billing for ultrasound is that it is not a professional fee but does require recording and reporting of the ultrasound imaging as part of the record.
Now I just need to figure out if this is applicable to an infusioin center; if they can bill as an ASC for instance. Both the Bard and Cook CPT lists indicate that there are professional fees for "in office", but only list facility fees for outpatient or ASC.
An infusion clinic would be a form of outpatient or ASC. You would bill the facility fee but not the professional fee unless the actual procedure was done by an MD, NP, or PA. Then those individuals would bill according to the professional fees established for each. No facility, regardless of what type, can bill a professional fee. Lynn
Physician office is just that a MD office. A outpatient infusion center that is not a MD office is not an MD ofifice. MD's may bill Medicare. Not eveyrone gets paid by Medicare. MD true MD office who may have an infuison clinic on siite owned by MD group or MD can bill a for one flat fee for PICC insertion. Materials and labor are included. The payment is under $400 which includes all labor and materials. That is on the Bard website. An MD can also bill for ultrasound if used but musat have picture. The MD if they have x-ray on premise can bill for x-ray for tip positioning. At max with all of this you are looking at $400-$425.
Ambulatory surgery center entirely different. You must be classified as a non physician office and actually be classified as an ASC to bill this way. There are two payments here. One for MD professional use of placement and equipment which is about $100 and one for materials.
There is no medicare reimbursement for a PICC to be placed in a patient's home or a ambulatory infusion not owned by an MD or in a nursing home or speciality care. Medicare pays for outpatient hospital PICC insertion
Is the inserting RN an employee of the office or clinic? If so, there should be a bill for the insertion by the facility, however no professional fee should be billed. Professional fees are what the MD, NP or PA can bill but only for the procedures they actually perform. If the inserting RN is a contractor doing the insertion, he/she sends a bill for the insertion service to the office/clinic. This bill should be based on a prearranged contract between the inserting RN and the office/clinic. Again, the office/clinic can bill for the insertion but no professional fees can be billed by the MD. Someone please correct me if I am wrong on this, however my understanding has always been that the MD, NP, or PA can only bill professional fees directly to Medicare, private insurers, etc. for services they directly perform. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thanks Lynn,
This is for a contracted service with the insertion being billed to the office/clinic. I am trying to figure out how the office could bill payors and maximize reimbursement. Looking at the document published by Cook Medical "2012 Coding and Reimbursement Guide" (http://www.cookmedical.com/ir/content/mmedia/IR-BM-CPPPCR-EN-201203.pdf), I am trying to figure out how the CPT codes for outpatient insertions could work in a private office or infusion center.
CPT codes are specifically used for those outpatient settings, so that is what is used for all procedures. There are 2 different types of billing - the facility/hospital/clinic bills for the procedure and the professional billing for a procedure which is ONLY open to MD, NP, and PA. The MD, NP or PA must do the actual procedure in order for them to bill a professional fee. The office/clinic bills the regular fee without adding the professional fee. If they do add the professional fee when someone else has actually performed the procedure, that could be regarded insurance fraud!! Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Look closely at that Cook list. Notice the footnote of 1, 2, 3 by the columns with $$. There is a facility fee column and the one with a footnote of 3 is a professional fee. When a contracted service places the PICC, the facility can be billed. The professional fee can not be billed. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Our billing dept added the ultrasound code to the PICC code since all are placed via realtime US. That would not be considered a professional fee would it?
thanks,
At one point, there were some issues with this, but I am not sure about the current correct answer. Hopefully someone else will know. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
My understanding of billing for ultrasound is that it is not a professional fee but does require recording and reporting of the ultrasound imaging as part of the record.
You will find physician office on Bard website
Problem is when placing a PICC in MD office it includes not only labor but all materials as well. The total payment is around $400 with ultrasound
Not very high
Kathy
Now I just need to figure out if this is applicable to an infusioin center; if they can bill as an ASC for instance. Both the Bard and Cook CPT lists indicate that there are professional fees for "in office", but only list facility fees for outpatient or ASC.
An infusion clinic would be a form of outpatient or ASC. You would bill the facility fee but not the professional fee unless the actual procedure was done by an MD, NP, or PA. Then those individuals would bill according to the professional fees established for each. No facility, regardless of what type, can bill a professional fee. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
There seems to be lots of confusion on thisd
Physician office is just that a MD office. A outpatient infusion center that is not a MD office is not an MD ofifice. MD's may bill Medicare. Not eveyrone gets paid by Medicare. MD true MD office who may have an infuison clinic on siite owned by MD group or MD can bill a for one flat fee for PICC insertion. Materials and labor are included. The payment is under $400 which includes all labor and materials. That is on the Bard website. An MD can also bill for ultrasound if used but musat have picture. The MD if they have x-ray on premise can bill for x-ray for tip positioning. At max with all of this you are looking at $400-$425.
Ambulatory surgery center entirely different. You must be classified as a non physician office and actually be classified as an ASC to bill this way. There are two payments here. One for MD professional use of placement and equipment which is about $100 and one for materials.
There is no medicare reimbursement for a PICC to be placed in a patient's home or a ambulatory infusion not owned by an MD or in a nursing home or speciality care. Medicare pays for outpatient hospital PICC insertion
Kathy Kokotis