Facility billing is insurance billing for hospitals, inpatient or outpatient clinics, and other offices such as ambulatory surgery centers. This insurance billing is not the same as billing for a regular doctor or specialist.
Facility billing is required to be submitted on UB04 forms instead of the more common CMS 1500 forms. The information required on UB04 forms is different than the information required on the CMS 1500.
For example, UB04 forms require rev codes and a type of bill code that are not required on the CMS1500 form. There are also a lot of “conditional fields” that for most situations are not required to be completed. It is important that you know how to complete the UB04 form correctly in order to get reimbursed properly from the insurance carrier.
Some offices may bill as both facility and professional billing. We bill for an outpatient drug and alcohol rehab facility that is owned by an LCSW. Some insurance carriers have it credentialed as a facility and require the billing to be done on UB04 forms. This is beneficial to our client because the facility reimbursement rate is higher than the professional reimbursement rate. But other insurance carriers will not credential him as a facility and he must bill services out to them on CMS1500 forms as regular therapy visits.
So you may find yourself in a position where you need to bill out on both the UB04 and the CMS 1500 forms. In any case, it is crucial that you are completing the forms correctly.
When we first learned how to submit UB04 forms, they were actually still the old UB92 forms. We had to purchase a book called the UB92 editor which is a very detailed book on what all the fields on the UB92 form are for. It was helpful, but it actually contained too much information. The book is hard to navigate and is actually quite costly. The information in it is required if you are doing in depth inpatient billing, but for the littler guy, such as outpatient clinics, it is too much info and too difficult to decipher. We receive tons of questions from people who are trying to complete a UB04 form properly.
In order to complete the UB04 forms correctly for facility billing, it is very important to understand the differences in billing procedures between the CMS 1500 forms and the UB04 forms. Make sure your claims are paid correctly the first time they are submitted.
Copyright 2007- Michele Redmond