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Physician Billing for Ketamine infusion in HOPD

Melissa Posted Wed 25th of January, 2017 15:14:22 PM
Hello, Our physician is contracted by a hospital to provide services in the Hospital Outpatient Pain Clinic. They are going to start doing Ketamine Infusion for pain control. The patient will typically stay 4 to 6 hours. Can the physician bill for a professional component of this or does he bill an E&M code and the hospital bill for the 96365 etc. Thank you
SuperCoder Answered Fri 27th of January, 2017 03:18:26 AM

Hi,

 

 

CPT code 96365 is a global code and cannot be split into professional component (26 modifier) and technical component (TC modifier).

 

The billing for his part of services can be done as under:

 

  1. Facility can bill for the infusion code (96365) and pay the dues to the provider (for performing infusion).

     

  2. The provider can also directly bill for his service.

     

  3. If the infusion was planned, then the E/M cannot be billed as it would be inclusive of the infusion service component.

     

  4. If the E/M service is provided for other than the infusion, then the provider can report appropriate E/M code along with 25 modifier.

     

Note: Use 96365 for each initial IV infusion of a drug. The documentation for all infusion codes must specify the name of the drug or other substance used for the infusion.

 

If the provider performs IV infusion of the same drug for more than one hour, use add on code 96366, Intravenous infusion, for therapy, prophylaxis, or diagnosis specify substance or drug; each additional hour.

 

Thank you!

Melissa Posted Thu 02nd of February, 2017 12:15:46 PM
Hi, I am not sure I understand completely. When you say the provider can bill directly for his services, what do you mean? Is there an Anesthesia monitoring code that would be appropriate to bill for his supervision? Thank you
SuperCoder Answered Fri 03rd of February, 2017 05:50:17 AM

CPT code 96365 is a global code and cannot be split into professional component (26 modifier) and technical component (TC modifier). 

There are 2 ways to bill for the services:

As the service was rendered in the outpatient pain clinic set up, so the provider who performed the services can directly bill for his services delivered.

If he performed the infusion in the hospital outpatient pain clinic, he can bill infusion code 96365 (without any modifier). If he also performed the E/M for the planned infusion, then the E/M would be considered included in the infusion service.

 

If the E/M service is provided for other than the infusion, then the provider can report appropriate E/M code along with 25 modifier.

 

It is a mutual understanding between the provider and the hospital outpatient set up, how to get the services reimbursed.

 

The facility (outpatient pain clinic) can bill on behalf of the provider, in this case, your provider CANNOT bill separately.

 

Or else, your provider can bill for his services separately, in this case, facility CANNOT bill separately.

 

Thank you!

 

Melissa Posted Fri 03rd of February, 2017 10:14:07 AM
Thank you----one last question....in the CPT book it says 96365 cannot be billed by the physician that would mean it can only be billed by the outpatient clinic...so the only way he can be reimburse for his services is through an arrangement with the hospital?
SuperCoder Answered Mon 06th of February, 2017 03:05:46 AM

Hi,

 

As per the coding guidelines 96365 is not intended to be reported by the physician in the facility setting. So, in order to get the reimbursement for service rendered, hospital outpatient can bill on behalf of the physician.

 

Thank you!

 

 

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