Outpatient hospital billing and CPT questions list

OUTPATIENT HOSPITAL

Is a pre-certification required from Health Care Excel (HCE) for outpatient services and/or surgical procedures?

No, a pre-certification from HCE is not required for outpatient services and/or surgeries.

If a hospital has an outpatient claim that requires the submission of a second page for services provided on the same date, should two separate claims be filed or can a two-page claim be submitted with the total appearing on the second page?

In this instance, the provider should submit two separate claims and total each individual claim page. When billing for an outpatient facility charge, should a CPT/HCPCS code be entered in addition to the outpatient facility revenue code?

No. Enter only the appropriate outpatient facility revenue code. Do not list a CPT or HCPCS code along with the facility revenue code.

Can a provider bill for two emergency room visits on the same day for the same patient?

If the second ER visit is essentially for the same reason as the first, the hospital cannot bill for it. If the second visit is for a different reason, the hospital can bill for the visit. The two visits must be billed on the same paper claim and the ER notes for each visit attached to it.

If the patient has two ER visits on the same day at two different hospitals, whichever hospital submits a claim first will be paid. The provider that bills second will have its claim denied and will have to refile a paper claim with the ER notes attached to it.

How are emergency room services billed that continue from the initial day into the following day?

For any ER service that continues past midnight, including the facility charge, use the date the patient was initially seen in the ER as the date of service.

How are observation services billed that continue from the initial day into the following day?

For any observation room services that continue past midnight, including the facility charge, use the date the patient initially was put in observation as the date of service. Bill only one observation room facility charge for the entire stay. Do not bill one for the first day and a separate one for the second day.

Can a hospital bill for multiple dates of service on the same claim for either emergency room services or therapy services and use the AJ condition code to exempt the patient from the $3.00 cost sharing amount for each date of service reported on the claim?

No. Only one date of service can be reported on an outpatient hospital claim on which the AJ condition code is reported. The AJ condition code is used on the outpatient hospital claim to exempt the patient from the $3.00 cost sharing for emergency room services or outpatient therapy services (physical therapy, chemotherapy, radiation therapy, psychology/counseling and renal dialysis).

A MO HealthNet patient presents to the hospital emergency department for non-emergent care. Eligibility is checked and it is determined the patient is administratively locked-in to a provider. The ER department tries to contact the designated lock-in provider who either is not available or will not authorize the services through the PI-118 lock-in form. Since the ER department cannot get a referral from the lock-in provider, can these services be billed to the patient or does the hospital have to write them off?

The patient can be billed for the care. Patients who have been administratively locked-in to a designated provider know this and know who their lock-in provider is. Further, they know that if they try to obtain non-emergent services from another provider, the patient can be held responsible for the costs of the service if the treating provider is unable to obtain a referral from the lock-in provider.

How does a hospital bill for an injection for which there is no J-code?

If there is no appropriate J-code for an injection, the hospital can bill one of the following codes.

J-3490 – unclassified drug

J-7599 – immunosuppressive, not otherwise classified

J-8499 – prescription drug, oral, non-chemotherapeutic, NOS

J-8999 – oral prescription, chemotherapeutic, NOS

The injection code can be filed on a paper UB-04 claim form. An invoice must be attached which shows the name, the national drug code and the cost for the drug. The injection code also can be billed on the emomed.com electronic UB-04 claim form. 

If the claim is filed using this method, then a provider must click on the "Add/View Invoice of Cost" link at the bottom of the claim Web page. This opens up a Web page titled "Invoice of Cost Information" page which must be completed and submitted along with the claim.

Can the hospital bill for a non-payable medication under medical supplies?

No. An injection or medication that is not payable under MO HealthNet cannot be billed under revenue code 270 (medical supplies).

Are hospital’s required to keep paper copies of attachments used for physicians’ outpatient services, e.g. Second Surgical Opinion Form, Sterilization Consent form, etc.?

Yes. The hospital must maintain a copy of these forms in the patient’s permanent file.

Can HCPCS “Q” codes be used to bill for MO HealthNet services?

HCPCS “Q” codes are national codes given by the Center for Medicare Services (CMS) on a temporary basis. In general, “Q” codes are not to be used to bill for MO HealthNet services and are considered non-covered.

Does MO HealthNet have allowable quantities that can be billed for outpatient services?

Yes. Each procedure code has an allowable quantity that can be billed to MO HealthNet without additional documentation. A provider can access the MO HealthNet fee schedules, which include allowable quantities, through the MO HealthNet Division Web site, www.dss.mo.gov/mhd/providers/index.htm. 

Note – The fee schedule for the technical component of laboratory procedures does not include hospitals. Contact Provider Communications, 573/751-2896, for information relating to the allowable quantity and reimbursement for outpatient laboratory procedures.

How is a claim billed when more than the allowable quantity of a procedure was performed?

A provider cannot bill for more than the MO HealthNet allowable quantity on a single line on the claim. The additional quantities have to be billed on subsequent lines and the hospital’s notes sent with the claim for manual review and processing. 

Example - the MO HealthNet allowable for a procedure is two but the hospital wants to bill for five. The hospital would bill one line with the procedure code and a quantity of two, a second line with the procedure code and a quantity of two, and a third line with the procedure code and a quantity of 1, and the hospital notes submitted with the claim.

What is the proper way to bill for a comprehensive metabolic panel, procedure code 80053?

If only CPT code 80053 was performed, bill the code without any modifiers. Providers should be aware that 80053 might be included in CPT code 80050 (general health panel) if certain other lab services are being billed for the same date of service.

CPT code 80050 includes 80053 in addition to:

Blood count, complete (CBC), automated and automated differential WBC count (85025) or (85027 and 85004) or,

Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009)

Thyroid stimulating hormone (TSH) (84443)

What is the correct way to bill for outpatient cardiac rehabilitation services?

Providers should bill using the appropriate revenue code, 0943 - cardiac rehabilitation. Do not list a CPT procedure code with this revenue code. Are there special documentation requirements for billing for outpatient missed abortions/miscarriage services?

MO HealthNet does not cover elective abortion services.

Any claim with a diagnosis of miscarriage, or missed or spontaneous abortion, diagnosis codes 632, 634.00-634.92, 635.00-635.92, 636-636.92 and 639-639.9, must be submitted on a paper UB-04 claim form with all appropriate documentation attached. 

The documentation must include the operative report, an ultrasound, the pathology report, the admit and discharge summary, etc. to show that this was not an elective abortion. If no ultrasound was performed, the reason for not performing it must be clearly documented in the patient’s medical record.

The above information is required also when submitting a claim with one of the following CPT codes: 59200, 59812, 59821, or 59830.

CPT codes 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, and 59866 also require a completed Certification of Medical Necessity for Abortion form in addition to the previously noted documents.

Observation Care: Are You ‘Inpatient’ or ‘Outpatient’? It Makes a Difference

If you are in the hospital, occupying a bed, are you an inpatient of the hospital, or not? You probably think you are, but that may not necessarily be true. Here’s why:

Being ‘inpatient’ means you have been formally admitted to the hospital with a doctor’s order. Being ‘outpatient’ means that you are getting emergency department services, observation services, or having outpatient surgery, tests, etc., at the hospital, but a doctor has not written an order to admit you into the hospital. 

The amount of time you spend in the hospital, even if it is overnight, does not determine your hospital status. You are not an inpatient until you are admitted to the hospital formally on a doctor’s order.

Outpatient observation services are performed in a hospital on the hospital’s premises, including use of a bed and at least occasional monitoring by a hospital’s nursing or other staff, to help your doctor determine if it’s necessary to admit you formally to the hospital as an inpatient, or if you can be discharged. Generally, patients are not kept in outpatient observation status for more than 48 hours.

Why does your hospital status matter? 

Your status, inpatient or outpatient, has an effect on how Medicare pays the hospital, and how much you may have to pay for the hospital services. 

You can pay more for services received when you are in outpatient hospital observation status because instead of being responsible for one Part A deductible for all of your hospital services, you are instead responsible for a separate copayment for each outpatient hospital service. 

The total of your copayments for outpatient services, including tests, procedures and observation, can be more than your Part A deductible would be as an inpatient. 

Also, Medicare Part B does not cover self-administered drugs, including your prescription drugs and over-the-counter drugs that you may receive as an outpatient.

What determines whether you are admitted as an inpatient? Generally, you will not be admitted as an inpatient if you are not expected to need medically necessary hospital care for two of more midnights.

Here are some examples of how Medicare pays for observation services:

• I am admitted to the hospital from the emergency room, based on a doctor’s order. Part A will pay for the hospital stay, and Part B (Railroad Medicare) will pay for the doctor’s services.

• In another scenario, I visit the emergency room, I am sent to the intensive care unit or any other room so that my condition can be monitored. My condition gets better and the doctor lets me go home. Part A pays nothing, and Part B (Railroad Medicare) pays for the doctor’s services.

• In cases where Part A does not pay, the outpatient services (such as the doctor’s services, lab services, radiology/x-rays, etc.) are paid for by Part B. I pay my deductibles and co-pays out of pocket. Each of these services is billed separately.

• I visit the emergency room and the hospital staff keeps me for two nights. If one of those nights a doctor writes an order for me to be admitted to the hospital, Part A will pay for my hospital stay, and Part B pays the rest, minus my deductibles and co-pays.

There are many other cases and scenarios and situations in which Part A may or not pay. The most critical situation is for patients going to a skilled nursing facility (SNF) after a hospital stay. 

If the beneficiary has not been a hospital inpatient for three consecutive days, Medicare will not cover the SNF stay or services – regardless if the patient was physically at the hospital for three days or more.