The updated policy applies to both KY and NY commercial plans. If you are a provider that providers services in outpatient hospital (facility) setting, then this blog post is for you!

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What is changing?

Professional services billed on UB-04 claim facility form will not be reimbursed unless federal/state contracts indicate otherwise.

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Professional services that are billed on UB-04 will require 3 different modifiers, listed below.

• PN- modifier billed for any outpatient procedure/surgery performed on off-campus location and are not contracted under the hospital contract – rebursement- 40% of allowable rate
• Modifier PO- is used for any outpatient procedure/surgery performed at a off-campus hospital department location.
• Modifier ER- physician performed services  performed at off- campus ER department.

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Modifier 26– professional services- when the professional services are billed on UB-04 facility claim with this modifier no separate reimbursement will be allowed and it will be denied.

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Professional services that need to be billed on HCFA-1500 form:

• E/M services rendered both on off-campus and on hospital campus
• Preventative  counseling services performed in outpatient facility setting

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Reimbursement exeption:

• 40% reimbursement does not apply to pathology and drug codes/services.

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Revenue codes: 960-989:

• Should not be billed on UB-04 claim form – no separate reimbursement
• Should be billed on HCFA-1500 form with corresponding hcpcs/cpt codes

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Codes: 99281 – 99285, G0380 – G0384: ER professional services should be billed on HCFA-1500 form.

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