Hospital Based Outpatient Billing refers to the process of billing for items and services that are rendered in a facility that is designated as a hospital outpatient or clinic location. This is a national model of practice for large integrated health care delivery systems where the hospital owns the practice and employs the support personnel involved in patient care. Some audiology departments associated with hospitals submit claims as a hospital outpatient department. Others are structured in a manner where the audiologists are employed by a large office setting group practice that submits claims as a non-hospital provider.
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Q: How does Hospital vs. Office billing affect patient billing?
A: Hospital claims are typically submitted on a UB-92 form. Office claims are typically submitted on a CMS 1500 form. Under the “Hospital-Based Outpatient” model, for some services, the patient may receive two charges on their patient bill. One charge represents the facility fee (TC or technical component) and one charge represents the professional fee (-26 or professional component).
Q: Do you have an updated list of APC rates by CPT code or do you know where I can access that information?
A: The rules for Hospital Outpatient Prospective Payment System are published in the Federal Register.
Q: How do you suggest setting our rates? Should they be based on APC or Fee schedule?
A: The Academy cannot make recommendations on how hospitals or providers should set their rates.
Q: For CPT codes that have a Technical and Professional Components (i.e., vestibular function tests, ABR and OAE) should we as a hospital bill and be paid:
- For the global value by submitting bills in the UB92 format? (if yes, how do we note that the bill is for the global value and not just the technical?)
- For the technical and professional components separately? (if yes, how do we note that the bill is for the technical component only on the UB92 and for the professional component on the CMS 1500 form?)
A: Hospital outpatient payment is for technical component (TC) only. A hospital bills for the TC and the audiologist bills the professional component (-26). The hospital may bill for the TC using the UB-92 form and the audiologist would bill for the PC alone using the CMS-1500 form. The key factor is whether or not the hospital provides the equipment, room space, hospital personnel, etc. If they do, then they bill for the TC. The modifier reflects whether it is the technical component (TC) or professional component (-26); reporting the code without a modifier indicates the global value (both technical and professional component).