Saturday, June 18, 2016

Outpatient Rehabilitation Facilities Billing Requirements



• Multiple dates of service should not be grouped on one line.

• Indicate “74X” or “75X”’ type of bill, which is field 4 on paper claims

o First digit – Type of facility (7)

o Second digit – bill classification (4 for outpatient rehabilitation facility or 5 for comprehensive outpatient rehabilitation facility)

o Third digit – frequency (e.g., admit thru discharge claim)

• The individual therapist providing occupational, physical, and/or speech therapy may not bill separately for services provided in the facility. The facility should bill these services using the appropriate CPT codes.


PSA Facility Transfer

The Psychiatric and Substance Abuse PSA facility must agree to transfer a member requiring acute care medical or surgical services, in a non-emergency situation, to the nearest participating provider that can furnish covered services.

• Do not bill the member for services that are deemed by Florida Blue as not medically necessary. The facility may bill the member for non-covered services per the member benefits.

• When two or more diagnoses are made for the same case, the primary diagnosis for billing purposes will be the diagnosis that precipitated the admission. The facility must bill the primary diagnosis as substance abuse unless a psychiatric condition is clearly the reason for admission, and can be substantiated by treatment plans, medical records, and psychological evaluations. Bill 23-hour observations as an inpatient service with a “111” type of bill, as well as separate admits and discharge dates.

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