Inpatient Ultrasound Services provided by a Private Office located in proximity of the Hospital

The SMFM Coding Committee frequently receives questions on the appropriate way to report and receive reimbursement when ultrasound services are provided to hospitalized patients.

Global Billing-services are provided and can be billed as Global only when the practice:

* owns or leases the equipment,
* owns or rents the space where the scan is performed, and
* Compensate the staff performing the scan (MD and/or sonographer).

These conditions are applicable when scans are performed in the hospital, unless provisions have been made for space and equipment rental.

Professional Component Billing –Modifier 26

Ultrasound services are comprised of a technical component and a professional component. The technical component (Modifier TC) reimburses for personnel, equipment, and the space where the service is performed. The professional component (Modifier 26) reimburses the physician’s time in performing the diagnostic service, the professional interpretation, and communicating the results to the patient. In general, services provided in a facility setting, such as a hospital, (whether Inpatient POS [Place Of Service] 21 or Outpatient POS 22), are reimbursed to the facility for the technical component, while the physician must bill with modifier 26 for the professional component only.

In many hospitals inpatient diagnostic imaging services, both technical and professional may be included in a "bundled" daily rate based on the Diagnostic Related Group (DRG) codes reimbursed by the (IPPS) Inpatient Prospective Payment System to the hospital. The hospital receives a daily fee for diagnostic services (radiology, lab and ultrasound) per patient, regardless of the number of services performed. This can pose a problem for specialty providers such as Maternal-Fetal Medicine physicians when they’re asked to provide diagnostic services to inpatients. For example, if an MFM physician performs an ultrasound, he/she bills the insurer and receives a denial stating that diagnostic services are included in hospital payment. When this occurs it is because the services rendered are included in a daily hospital fee. The MFM practice must then negotiate with the hospital (not the insurer) for the technical and/or professional component reimbursements. If the hospital inpatient diagnostic imaging service does NOT include the professional component in the "bundled" daily rate based on Diagnostic Related Group (DRG) codes reimbursed by the (IPPS) Inpatient Prospective Payment System to the hospital, then the physician should bill for the service using the 26 Modifier. Unfortunately CMS and most payers who follow CMS guidelines will only pay the physician for the professional component when services are performed in a hospital setting, either inpatient or outpatient, regardless of whether the space used is being rented. Rarely your contract may specifically state a “No Site of Service Differential” stipulation and you will be reimbursed for the global ultrasound service.

If the hospital inpatient diagnostic imaging service does NOT include the professional component in the "bundled" daily rate based on Diagnostic Related Group (DRG) codes reimbursed by the (IPPS) Inpatient Prospective Payment System in the hospital, then the physician should bill for the service using Modifier “26”.

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SMFM Coding Committee’s suggested action plan:

* Do not submit global ultrasound services to any payer for inpatients to prevent fraud and compliance risks for “Double Billing”.
* Only one interpretation and report for the same x-ray (or ultrasound) is reimbursed, so we cannot bill for re-reading images already billed for by radiologists.
* Due to the CMS edit placed in 2007, some commercial carriers adopted the edit and automatically reimbursed the claim “Professional only” when a global claim was received, BUT some carriers did not.
* Correct all global claims to professional only claims immediately. If the global claims are not corrected within the carrier’s time filing limit, your professional reimbursement is at risk to be lost. Submit all inpatient ultrasound bills with modifier 26 “Professional Component” across all payers UNLESS a specific payer has a “No Site of Service Differential” stipulation in the contract that will reimburse the provider globally when a patient’s status is “Inpatient”
* The Technical Component reimbursement may be negotiated and recovered from the Hospital for services MFM’s provide depending on factors such as ownership of equipment and space.
* Build edits in your system to avoid “Inpatient” Ultrasound claims being submitted globally.