Outpatient Services

Introduction

Outpatient hospital services are preventive, diagnostic, therapeutic, rehabilitative or palliative items or services furnished by or under the direction of a physician to an outpatient recipient by an institution that is licensed as a hospital. Outpatient bills, UB-04, are required to indicate revenue codes, procedure codes, and units (except revenue codes 25X and 27X).

Reimbursement Guidelines

Effective October 1, 2009, Outpatient Hospital Facility claims with dates of service October 1, 2009 or greater will be subject to the new Ambulatory Payment Classification (APC) Fee Schedule.  For more additional information, see Provider Type Hospitals.

Laboratory Services

Laboratory services, revenue code range 300 – 319, are reimbursed based on the Medicare usual and customary rate (UCR) for the procedure code. Panel billing for laboratory services is required.

Surgical Services

Surgical services performed by the facility are reimbursed at the outpatient surgical RCC percentage of charges.

Dialysis

Dialysis facilities must bill on a UB-04 claim form using an outpatient bill type. Reimbursement is based on the revenue codes billed to define the type of dialysis treatment rendered. Revenue codes 821, 831, 841, and 851 are all covered dialysis types and include all dialysis-related services rendered to the End Stage Renal Disease (ESRD) recipient, with the exception of the following codes:

  • Revenue code 634 and 635 for Epogen, 1 unit equals 1000 units.
  • Revenue code 636 for Calcijex (billed in conjunction with HCPCS code J0635), 1 unit equals 100mg. Limited to one unit per day.
  • Revenue code 636 for Infed (billed in conjunction with HCPCS code J1760), 1 unit equals 100 mg. Limited to one unit per day.

All dialysis facility billings are reimbursed from the fee schedule for Hemodialysis, Peritoneal, Continuous Ambulatory Peritoneal Dialysis (CAPD), and Continuous Cycling Peritoneal Dialysis (CCPD).

Professional Services

Professional services provided in an outpatient setting by hospital-based physicians must be billed on the CMS 1500 claim form.A physician provider number must be obtained through the provider enrollment process to correctly bill for professional services.Refer to the Provider Enrollment page for enrollment information.

Multiple Surgical Procedures

Multiple surgical procedures performed in an outpatient setting will be reimbursed on a decreasing percentage basis. The first or primary rate will be covered at 100% of the allowed rate; the secondary procedure is covered at 50% of the allowed rate; and the tertiary procedure is covered at 25% of the allowed rate. There is no additional reimbursement on the fourth or subsequent procedures. When billing for multiple procedures, the surgical codes must be listed in order of complexity..

Emergency Room Co-Payment

Recipients are responsible for a co-pay for emergency room (ER) visits if the services billed are deemed not to be a true emergency. The co-payment is not imposed for children under 18, IV-E and IV-E foster care children, adoption assistance children, pregnant women, and institutionalized individuals.

Use of an emergency diagnosis code is appropriate when patients, clinicians, or first responders believe that a situation requires immediate care and that lack of immediate care will result in death or significant harm to the individual who is symptomatic.

The hospital must bill the Medicaid Program with the appropriate ICD-9/ICD-10 diagnosis code, in form locator 66-77 on the UB-04 and description of emergency services. A provider may not deny service to a recipient who cannot pay the co-payment at the time the service is delivered.

Covered Services

All medically necessary services are reimbursable.

Medicaid covers observation for a limit of two days. After two days, the patient must be discharged to home or admitted as an inpatient. If admitted, the second observation day is billable on an outpatient claim and the admission is separately billable on an inpatient claim.

If a patient is admitted to observation status from the emergency room, both services are reimbursable on the same outpatient claim form. Observation status should be billed on a separate detail using revenue code 760, 762, or 769.

Non-covered Services

Multiple emergency room, clinic or outpatient visits are allowed for the same date of service (DOS). These may require supportive documentation to verify that services were medically necessary on the same DOS.

Venipuncture, handling fees and STAT charges are not reimbursable.

Limitations/ Special Requirements

Procedure codes requiring prior authorization (PA) are listed in Section 600-10 of the Provider Reference Manual. In addition, any unlisted CPT code billed requires PA. When requesting authorization, medical justification must be documented. PA procedures are on the Prior Authorization page.   

Claims Billing Guidelines

When a recipient is admitted as an inpatient from the ER, an outpatient claim and an inpatient claim must both be billed.

Late charges are billable services and should be indicated through the use of bill type 135. Only late charges should be submitted using this bill type.

Billing a span of dates in form locator six (6) to denote the from and through dates of service is not allowed except when billing for non-consecutive outpatient therapy services within a one month period. Billing for a span of dates should not exceed one calendar month.

Other Institutions

EOHHS will only reimburse the admitting facility for services provided to an eligible recipient during their entire length of stay. If a recipient is sent to another facility for services not available at the admitting facility, those charges must be billed on the admitting facility’s bill to EOHHS. If the second facility submits a bill to EOHHS, it will be denied. Reimbursement will be determined at the admitting facility’s RCC.

 

 

 

 

 

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