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Billing for Hospital and Hospital Based Clinic Services

This topic contains 2 replies, has 2 voices, and was last updated by  amandagal 3 days, 22 hours ago.

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  • #23463

    amandagal
    Participant

    I sat down with my pharmacy director today and he was interested in talking about setting up a hospital MTM program. I didn’t have answers to all his questions (and this isn’t the reason I signed up for the course, but I guess I’ve talked about MTM enough that he was interested). I’m pretty confused about hospital-based billing. Does anyone work in health system? He’s concerned that the ideas sound great, but admin isn’t going to want to do anything that requires extra staff AND doesn’t make money.

    1. If we did inpatient bedside discharge MTM, could we potentially bill for that? I told him we could probably bill using the same codes we used for therapeutic drug monitoring. He said we don’t bill for those. I’m pretty sure we SHOULD bill for those. Does anyone have a resource for that information? I’m going to keep looking, but if someone knows what direction to look in, that would help.

    2. We also have a clinic. I told him we could do MTM there and use incident-to physician codes. He wasn’t sure because it’s connected to a hospital. I can’t find anything that says those codes aren’t good for hospital connected clinics.

    3. This is a weird situation. We do a comprehensive rehab in the clinic which includes diet (dietician on demand), exercise (with an exercise physiologist) and general lifestyle teachings. I think a pharmacist on demand would be excellent there, but I’m not sure how to pay for it. I’ve seen the bills and it seems like Medicare just bills it as one fee no matter what happens. Does anyone have any experience with a situation like this? My idea was to schedule the patients outside of the rehab center and bill like you would a clinic MTM patient, using the incident-to codes, but he was concerned that wasn’t legal.

    Thank you. The only thing I’ve learned is that hospitals are a lot more difficult than physician clinics. I thought my director would know more about billing than I do, but he seemed to know less!

    • This topic was modified 1 week, 5 days ago by  amandagal.
    #23537

    Blair Thielemier
    Keymaster

    1. Hospital billing is tricky because you can’t bill incident to, but you can bill for stuff like TCM and get an additional “facility fee”.

    Which codes are you using for therapeutic drug monitoring? I would be happy to do some research to see if they’d apply.

    Other resources I like are this whitepaper from the Advisory Group.

    Also, see part 2 of my webinar notes on this subject in this forum thread.

    2. Here’s some more info about incident to billing in a hospital clinic

    Billing incident to physician in a hospital-based outpatient clinic (same tax id# as hospital)
    Place of service code for hospital based clinic – 22
    POS code for physician outpt clinic – 11
    POS code for pharmacy – 1
    POS code 19 consider “off-campus” hospital based clinic (past 250 yards)
    100% same for Medicare reimbursement
    Medicaid reimbursement may be a bit different
    If rph billing incident to in hospital-based outpt clinic, they can only bill for facility fee (FF)
    FF are overhead charged by hospitals in order to compensate for supporting services
    Rph may contract directly with hospital or physician group
    Don’t bill PF if rph provides services
    CMS CRITERIA to bill incident to physician in a hospital based clinic
    Direct supervision (same building and immed available) and clinically appropriate to perform services
    Continued physician-patient relationship (estab pt ONLY), est plan of care, diagnosis and physician refers pt to rph
    Service is commonly furnished in physician office
    Must have physician “order” or “referral” in which physician states what service the rph will provide (specific dis state management – htn, dm, etc)
    Rph must have employee relationship with hospital – employee, leased employee, or ind contractor (must have contract with hospital)
    Rph follows scope of practice as dictated by their state board of pharmacy
    Ex) rph seeing 70 patients/week with G0463 = $271,095 according to Gloria’s pro forma

    Billing incident to physician in a physician-based outpatient clinic (owned by ind group, not hospital affiliated)
    May bill a facility fee (FF) and a professional fee (PF) = each time PHYSICIAN sees pt
    Direct supervision (same building and immed available) and clinically appropriate to perform services
    Continued physician-patient relationship (estab pt ONLY), est plan of care, diagnosis and physician refers pt to rph
    Service is commonly furnished in physician office
    Must have physician “order” or “referral” in which physician states what service the rph will provide (specific dis state management – htn, dm, etc)
    Rph must have employee relationship with hospital – employee, leased employee, or ind contractor (must have contract with hospital)
    Rph follows scope of practice as dictated by their state board of pharmacy

    CMS Facility Fee only billing
    CPT G0463 on CMS 1450 (AKA UB-04) billing TO Medicare
    APC code 5012 = $102.12 indicates payment received FROM MC
    Pt pays 20% of this copay


    Transitional Care Management – FIRST bundled payment model from CMS

    Qualified practice setting transfers
    Acute care hospital to home
    Psych hospital to domiciliary
    LTC to rest home
    SNF to assisted living
    Physician and npps are eligible to provide TCM
    Only appropriate for patients with moderate to high risk for readmission
    Multiple diagnoses
    Significant data to review
    Significant morbidity and mortality risk
    Service components
    Interactive contact (phone) within 2 business days
    ***CONSULTANT RPH OPPORTUNITY*** – Do the med rec now!
    Non face to face provided by licensed clinical staff member
    Face to face visit
    7 days for high risk
    14 days for mod risk
    Completed med rec BY DAY OF F2F VISIT!

    RPH role in TCM
    2 business day non f2f under GENERAL supervision
    Can be performed off-site
    Can have collaborative agreement with physician and/or hospital
    Biggest challenge is lack of resources
    Assist during f2f visit – med rec before or during visit and medication management services as appropriate
    Assist with f/u to optimize pt care during the 30 day post-hospitalization period
    AAFP documentation sheet with TCM 30-day worksheet
    If unsuccessful in contacting the patient within 2 bus days, but DOCUMENT attempts and must eventually make contact in 30 days
    FQHC and RHC not permitted to bill for TCM
    Claim submission can be 30 day post d/c OR on date of f2f
    If pt dies no payment is given
    Only one entity can bill tcm for a patient

    3. Here’s a great interview with Michelle Thomas about all the different things she does in her clinic, including diabetes management.

    I’m not sure how a rehab facility would be different than the hospital. I assume its billing under the hospital tax id number.

    Hope that helps!

    #23619

    amandagal
    Participant

    Thanks. It is a bit overwhelming. I think we really need to sit down with someone in our billing department and find out more information, but my boss is hesitant to do that without approval, and he’s hesitant to ask for approval before he has proof of concept.

    My partner and I will just approach them as consultants when we get up and running confidently, and we’ll show them how we can all make money, ha.

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