Facility Fees for Outpatient Services

From SmartMedicalConsumer Wiki

Facility fees are separate than the professional fees. For example, if you see your physician in an outpatient setting, you might be billed two different fees: a physician fee and a facility fee.

Facility fees are charged to cover the expenses due to staff other than the physician, such as nurses, and for office rent and other overhead.

You should know few things. Where you visit your physician may make a difference. The claim that your physician fills for reimbursement has a Place of Service Code. If the Place of Service Code (POS) is 11, this means the service is rendered in the Office, and your physician should not bill for a separate facility bill.

When you see a physician in an outpatient setting, the level of Evaluation and Management (E/M) service depends on the time the physician spends with the patient and/or family. The physician will charge you accordingly for this service. This physician fee is also called the professional fee.

If, for example, the Place of Service Code is 22 (outpatient hospital), then besides the professional fee, you may also be charged seperately for a facility fee.

Facility fees are confusing to consumers for many other reasons. Here is an example: For post-operative services (CPT 99024), the physician’s professional reimbursement is included in the payment for the surgical procedure. Thus, the patient should not be billed a physician fee. However, a facility fee may be billed.

Facility Fee Level

Facility fee is charged based on the facility fee level.

Facility fees are billed using Evaluation and Management codes from Current Procedural Terminology (CPT).

The Center for Medicare and Medicaid Services (CMS) have not mandated outpatient hospitals how to determine the facility fee level, however, they mandate that hospitals must have a documented process for determining facility fee levels.

Thus, if you have questions, your provider must be able to tell you how the provider determined the facility fee level for a given service. Furthermore, your provider must be able to provide the appropriate documentation to support any services billed for professional or facility.

Some providers determine facility fee level based on the quantity of nursing time used in the performance of the service. Here is an example:

• The physician will perform the appropriate service and indicate the level of Evaluation and Management (E/M) service.

• If there is no documentation of additional nursing resources utilized, e.g., via a Nurse’s note, then the nursing time for a specific service is considered to be equivalent to the physician service, and the E/M code level coded for the professional charge is matched for the

facility fee.

• When the nursing time exceeds the amount of time typically required by the level of E/M service indicated by the physician, the nurse should document the reason and the amount of additional time required. The facility fee level will reflect this additional time.