CMS Pub. 100-04, ch. 6, § 20.1.1.2

Services of a Physician

(Rev. 3230, Issued: 04-03-15, Effective: 06-15-15, Implementation: 06-15-15)

As noted above in section 20.1.1, physician services are excluded from Part A PPS

payment and the requirement for consolidated billing. When a beneficiary receives clinic

services from a hospital-based physician, the physician in this situation would bill his or

her own professional services directly to the A/B MAC (B) and would be reimbursed at

the facility rate of the Medicare physician fee schedule - which does not include overhead

expenses. The hospital historically has submitted a separate Part B “facility charge” for

the associated overhead expenses to its A/B MAC (A). The hospital’s facility charge

does not involve a separate service (such as a diagnostic test) furnished in addition to the

physician’s professional service; rather, it represents solely the overhead expenses

associated with furnishing the professional service itself. Accordingly, hospitals bill for

“facility charges” under the physician evaluation and management (E&M) codes in the

range of 99201-99245 and G0463 (for hospitals paid under the Outpatient Prospective

Payment System).

E&M codes, representing the hospital’s “facility charge” for the overhead expenses

associated with furnishing the professional service itself, are excluded from SNF CB.

Effective for claims with dates of service on or after January 1, 2006, the CWF will

bypass CB edits when billed with revenue code 0510 (clinic visit) with an E&M HCPCS

code in the range of 99201-99245 and, effective January 1, 2014 with HCPCS code

G0463.

NOTE: Unless otherwise excluded in one of the Five Major Categories for billing

services to A/B MACs (A), physician services codes are to be billed to the A/B MAC (B)

by the physician. Facility charges associated with the physician’s clinic visit must be

reported as explained above.