It is important to remember when it is appropriate to bill MO HealthNet an outpatient hospital facility charge. Inappropriate billing of facility charges will result in recoupment of payments. The following information can be found in the MO HealthNet hospital provider manual which is available at http://manuals.momed.com/manuals/. Please refer to sections 13.38, 15.20, 15.21 and 15.23 for more information regarding outpatient facility charges.
An outpatient facility charge should be shown on the claim if the patient sees a MO HealthNet enrolled physician, nurse practitioner or podiatrist for evaluation or treatment of the condition that caused the need for hospital services and the person who is registered on the hospital records being in an outpatient status. Services and supplies that may be included in the facility charges include:
- IV infusion services, including but not limited to: chemotherapy, antibiotic therapy, hydration therapy, immune globulin therapy, IV rate change and pitocin. Infusion therapy by nurses in an outpatient setting may be added to the outpatient facility charge.
- Services such as: venipuncture, specimen collection, taking and monitoring vitals, prepping, positioning, injecting, call-back services, stat charges, routine monitoring (e.g. fetal, cardiac, etc.), after-hours services; claim filing fees; education/instruction (e.g. colostomy care, cardiac care, etc.), handling charge for specimens referred to an independent laboratory, late discharge fee, preparation of special reports sent to insurance companies, psychiatric reports for court evaluation or juvenile court and standby equipment.
- The following operational cost elements: administrative costs, basic floor stock supplies, durable, reusable items or medical equipment, fixed building costs, furnishings, insurance, laundry, maintenance, nursing salaries, paramedical salaries, records maintenance and utilities.
Services that are not to be added to the facility charge:
- Services performed by hospital staff that are incidental to physician services; and
- Services provided by a physician assistant (PA), including those provided in an outpatient hospital-owned clinic.
If the following services are the only services provided during a visit, without any physician services, a facility charge must not be shown: physical, occupational or speech therapy; renal dialysis; injections/immunizations; laboratory/pathology; radiology; HCY/EPSDT services. These services can be billed by the hospital using the appropriate HCPCS Level I (CPT), Level II or Level III procedure code. The costs of diagnostic testing and treatment type equipment should be included in the charge for the specific service provided to the patient. The costs of hospital staff who are necessary to the performance of the specific service should be included in the charge for that service.
A facility charge code may not be billed by the hospital on the same date of service as cardiac rehabilitation unless a physician provided services on that day.
Only one facility code may be shown per date of service. If several physicians or clinics are seen, the charges must be combined into one facility code.
A charge for an observation service is not considered a facility charge. Therefore, as an example, a provider can show a surgery facility code and an observation code for the same date of service.