Forum - Questions & Answers

Sep 17th, 2019 - nate0922 7 

hospital codes

Can you use a 99213 for an outpatient/hospital setting? We use this all the time for an office visit (POS 11), but if we use it for an outpatient/hospital setting some insurance companies are applying a patient copay. That seems wrong to me to bill a copay when a patient is in the hospital. So, what should we use for an outpatient hospital consult for a Level 3? OR is this correct that insurance is now applying copay's for outpatient hospital care?

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Sep 18th, 2019 - ChrisW   151  1 

re: hospital codes

Yes, 99213 is used for office or other outpatient visits. Physicians are paid under the (MPFS)- Medicare Physician Fee Schedule, with that being said the place of service code triggers the payment between the office or facility. In other words, Physicians are paid under the applicable site of service and payment is adjusted accordingly. This is called the site of service differential. See the PUB-100 Claims Processing manual Ch 12. 20.4.2.

The co-pay pay or deductible could apply on all physician charges for outpatient services, that is correct. If they were seen inpatient their benefits would be different. You can call and verify with your payers if you feel this is incorrect, just be sure you are reporting the correct site of service, and if you call on benefits, let them know the setting where the services are being provided,

For example,
Outpatient Hospital-On campus, (POS code 22)
Outpatient Hospital-Off campus (POS code 19)

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

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