Provider Based Facility Fee

Hi All,

We are converting some of our clinics to provider based soon. I have the "G" code for Medicare but wondering what code to submit to private payors for the facility fee. We have a consulting firm that's assisting and they state we will just choose an E/M level to bill facility fee for the private payors.

Any help or advice would be greatly appreciated. I have to admit I do not have a lot of experience or knowledge surrounding this topic.

Thanks, Jeff


  • I recommend checking contracts and fee schedules.  Some private payors may be perfectly OK with G0463, others might want 992XX, and still others might refuse to accept provider based billing.
  • Thanks Andrew! I think our CFO and contract office are checking contracts. I could not find G0463 listed on several of our private payor's fee schedule. Just curious, do most people choose a "middle of the road" 992XX to submit? I know the fees will be the same regardless of payors and we are probably going to get plenty of denials. I am in the process of reading HCPRO's book "Provider Based Entities" , just haven't made it too far.

    Thanks Again for the response it was very helpful. Jeff

  • Most of our facility E/M charges are 99211 for a routine visit unless there is documentation to support that more than routine services were provided by the hospital/OP clinic staff.  Some of our commercial payers do not recognize this charge as being separately reimbursed on a UB claim.
  • We have guidelines for the facility visit based on non-separately chargeable resources required for care.  Similar to how an Emergency Department level is assigned.

    Many of our private payors require that the facility and professional charges be rolled up onto one line item on a claim, and they will not reimburse separately.  They also require the 99 codes.

    The payors weren't helpful in telling us if they prefer the G code to the 99 codes.   We essentially needed to find our way through trial and error (well denials anyway).

    Keep in mind you may need the PO or PN modifiers for departments newly registered as provider based.  Also, even if a payor accept the G-code, there may still be a revenue benefit to breaking the visit out by level.
  • To add on to my previous comments from 1/30/19, we do have a 99211/simple, 99213/intermediate, and 99215/complex levels mapped out with specific reasons/services to explain why a higher than 99211 might be coded/charged.  But typically, our facility E/Ms are at the 99211 level for a simple clinic visit or a provider based visit with the Physician/provider.  In some hospital OP areas, such as OB, we will have a greater mix of intermediate and/or complex levels charged depending on the services provided to the patient.  Hope that helps.
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