Difference Between Billing Professional and Facility CPT Codes

Medical billing is a series of complicated matters that requires enormous amounts of effort and understanding to perform. It contains different codes and descriptions that are intended to determine and facilitate payment and collection to keep your practice operational.

If you're aiming to dig into medical billing, whether you want to add it onto your skills or if you decide to hire an expert in medical billing, it is important to understand the nature of the job in different types of facilities. In the medical and midwifery world, codes work differently. Countless codes that need to be updated from time to time. There are ICD Codes, CPT Codes, HCPCS Codes, DRG Codes, Modifiers, etc. Each code has different usage and transcriptions that are used and designed within specific diagnostics. In this article, we will be discussing how professional fee and facility CPT codes differ from each other.

Professional and facility coding describe two very diverse aspects of the healthcare industry. Simply speaking, professional fee coding is the billing for the physicians and the experts. The facility coding is billing for the facility and the equipment. Professional codes primarily capture the complexity and intensity of provider care provided during a visit, facility codes detail the volume and intensity of hospital or health system resources used to deliver patient care, such as the use of medical equipment, medication, and nursing staff.
 
What is a Professional Fee Code?

Professional fee, refers to coding and billing the physician side of a patient encounter. Professional fee coding covers the work performed by the provider and the reimbursement they will receive for the medical services performed.

In general, midwives and midwife-led birth centers offer standard pregnancy care packages. This package covers the professional fee, all prenatal visits, labor and delivery care in a birth center, at home, or in a hospital, birth kits, newborn care and assessment, postnatal visits at two and six weeks postpartum, and phone consultations. On average, a midwife's basic maternity care package ranges from $3,000 to $6,000 for normal low-risk pregnancies. This can vary depending on the location or state where your practice is located. The basic package cost usually comprises prenatal visits, labor and delivery care, and postnatal visits.

To know more about midwifery reimbursement rates, here is a sample professional fee for CNMs and CMS MEDICAID FEE-FOR-SERVICE REIMBURSEMENT RATES FOR CNMs and CMs as of September 2013

What is the Facility Fee Code?

A facility fee is a charge that you may have to pay when you see a physician or a midwife at a clinic that is not owned by that physician or midwife. Facility fees are charged in addition to any other charges for the visit. Facility fees are often charged at clinics that are owned by hospitals to cover the costs of maintaining that facility
 
Hospitals, hospital-based facilities (such as outpatient clinics owned by a hospital), and various other medical facilities often charge a facility fee as well as the provider's professional fees. CMS regulations do not establish a general definition of “facility fee,” but CMS sets reimbursement rates for these fees subject to various requirements set forth below. The facility fee covers overhead costs, such as equipment, space, and support staff. This fee is sometimes referred to as the technical component of the bill.

Under the CMS “provider-based status” rules, Medicare will reimburse for facility fees at a hospital-based facility (such a group practice owned by the hospital) meeting certain requirements but not at providers' offices not affiliated with a hospital. A facility or practice has provider-based status and thus can bill for facility fees it if has a relationship with the main provider (i.e., the hospital) concerning a range of issues, such as licensure, clinical and financial integration with the hospital, public awareness, and billing practices. The regulations specify payment recovery procedures if a hospital inappropriately treats a facility as provider-based.

Facility Claim

A single facility claim is submitted for all services provided to the patient on that date.
●        Condition code is submitted in the claim header, letting the payer know that the evaluation and management (E/M) codes are distinct, potentially reimbursable services, and not duplicates.
●        The occurrence code and occurrence date at the header level indicates some of the services were related to an accident, which lets the payer know other medical coverage may apply for the services on the claim.
●        Revenue codes indicate the facility department or area
●        HCPCS Level II/CPT® codes
●        Diagnosis codes appear at the header level, not tied to a particular line

In order to bill the facility fees, the hospital or facility like a birth center should already have criteria for the codes they use. The Centers for Medicare and Medicaid Services does not specify these criteria, but expects them to form a bell-shaped curve. If the hospital has not established these guidelines, they could use and modify the suggestions published by the American College of Emergency Physicians, available at https://www.acep.org/administration/reimbursement/ed-facility-level-coding-guidelines/
Also visit https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ambulatory-care/Facility-Billing.pdf

Your practice will rely mainly on your cash flow. Professional fees and facility fees are the top two revenue streams of your business. Your clients must pay you with your expertise same with the facility you have been using to provide quality of service. As a practice owner, if you happen to create a unique system that collects these two types of fees and utilize it methodically, then you are on the right track and that is for sure.

References

Renee Dustman. (2015, February 1). Compare and contrast physician and outpatient facility coding. AAPC Knowledge Center. Retrieved August 6, 2022, from https://www.aapc.com/blog/29346-compare-and-contrast-physician-and-outpatient-facility-coding/

James Orlando, A. A. (n.d.). Facility fees and Accountable Care Organizations. Retrieved August 6, 2022, from https://www.cga.ct.gov/2014/rpt/2014-R-0238.htm
Understanding facility fees - the Alliance. (n.d.). Retrieved August 6, 2022, from https://the-alliance.org/wp-content/uploads/2021/05/TheAlliance_FacilityFees2021_EE_UnderstadningFees_6152021.pdf