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• Thread starter Thread starter aln2005
• Start date Start date May 21, 2018

Create Wiki A

aln2005

Contributor

Messages 12 Location Kansas City, MO Best answers 0 Been in coding for over 15 years on the physician side, however need help with inpatient billing. Can anyone give insight if modifiers, specifically the 59 modifier....if this is used on the UB92 for billing services that may be considered bundled? Any help from those that work on the inpatient side of things would be great! Thanks!!

Pam Warren

True Blue

Messages 2,654 Location Springvale, ME Best answers 1 -59 modifiers are not used for inpatient billing for the facility. Inpatient facility charges are reimbursed based on the calculated DRG, not on a fee-for-service model. Do you mean outpatient services? A

aln2005

Contributor

Messages 12 Location Kansas City, MO Best answers 0 I am definitely referring to facility charges. I have CPT codes 76000, 95939, 95938, 95868 and 95870 that are all denying with CPT code 22551. I honestly don't know how to rectify this issue if modifiers are not allowed for inpatient (UB92) billing. T

thomas7331

Guest

Messages 5,021 Location New Hartford, CT Best answers 17 Pam is correct - inpatient UB04 claims do not use CPT codes. CPT codes are not part of the inpatient code set for inpatient facility billing - in most cases it is not even possible to submit CPT codes on an inpatient bill as it will cause the entire claim to reject. What is your UB bill type? Are you sure this is inpatient and not outpatient facility? A

aln2005

Contributor

Messages 12 Location Kansas City, MO Best answers 0 Bill type 131- hospital facility. Is this different than inpatient? T

thomas7331

Guest

Messages 5,021 Location New Hartford, CT Best answers 17 Bill type 0131 is an outpatient hospital claim. Coding rules for outpatient facility claims, as far as CPT and modifier usage, are similar to those for professional claims, but the reimbursement methodology is very different. There are NCCI tables for outpatient facilities just as there are for physician, which you need to follow as far as use of the unbundling modifiers, but there is also a 'packaging' method of paying outpatient claims which is a different thing from bundling and can't be overridden with a modifier. In your example above, the CPT 22551, under Medicare APC reimbursement, is a 'J1' status code which is a 'comprehensive APC' category. This code pays a fixed rate which includes all ancillary services, so any other codes billed on the same claim are going to be package and will not have a separate line-item reimbursement. So your other codes are not denied, they are just packaged and inclusive to the case rate. Adding modifiers will not get those paid because the payment is already made in the rate calculation for 22551. If it's a different payer than Medicare, it may be driven by payer-specific or contract-specific rules and you would need to be familiar with your facility contract in order to know if the payment was correct or not. As a general rule, with facility claims you'll need to evaluate the entire claim for correct payment, not just the individual lines. If you're new to outpatient facility coding, you may wish to get some facility-specific training on how this works, and most facilities have access to a facility encoder which will perform these calculations for you and guide you in the coding and reimbursement rules. It's a fairly complicated area and there's a bit more to it than it's possible to capture in a forum post. A

aln2005

Contributor

Messages 12 Location Kansas City, MO Best answers 0 Thomas you have shed light on this topic for me, and I genuinely thank you! You must log in or register to reply here. Share: Facebook X Bluesky LinkedIn WhatsApp Email Share Link

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