I work for a small police department. When an inmate has to go to the ER, by state law we are only required to pay the Medicaid rate. We do not have any kind of insurance that covers this, so it comes directly out of our budget.
A person was sent to the ER after fleeing the police and crashing his vehicle. He had a CT scan of his head w/o contrast (70450) and an x-ray of his spine (72100). We received a bill from the hospital as well as the physician's office billing these two CPT® codes with no modifiers.
Forgive my ignorance, but I've done a little research and it would seem to me that the hospital should have used the TC modifier and the physician's office should have used the 26 modifier. By not using the modifiers, isn't this considered "global" billing and essentially the hospital and physician's office are billing for the same service?
Because we are such a small agency, every little bit we can save helps, so any guidance you can give me is greatly appreciated.
hmmm, the physician that interpreted the images is not employed by the hospital if you are receiving a separate bill. You are correct in the TC (technical component) and 26 (interpretation) modifiers.
Now, there is a difference in price for coding. If the hospital uses TC, they get a PORTION, and the physician uses 26, they get the other PORTION. If no modifier is used, the full allowable is paid.
Example: (not real prices)
72100 Allow $36.00
72100 TC Allow $24.43
72100 26 Allow $12.09
You shouldn't pay full allow to BOTH. It should be priced out accordingly. I am in Arizona, and I have access to Medicare Fee Schedule. Not sure if you can find your state on the CMS website. But it is a good negotiating tool if you can. Good luck!
Unfortunately, there will always be 2-3 bills in an emergency visit. One for the hospital, which is a facility bill (usage of equipment, supllies, etc.), then the physician bill (who is treating the patient), then possible xrays (interpretation) or what not, they also bill seperately. Physicians mostly do not work for hospitals. They are like subcontractors. They work for themselves.