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Billing for freestanding emergency department visits

Billing guidelines for freestanding emergency department charges may differ from what you expect.

November 30, 2022
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Billing guidelines for freestanding emergency department (ED) charges in Workers’ Compensation may differ from what you expect. The Colorado Division of Workers’ Compensation (DOWC) identifies two types of ED visits:

(i) Hospitals billing type “A” ED visits must be physically located within a hospital licensed by the CDPHE as a general hospital or meet the out-of-state facility’s state’s licensure requirements and be open 24 hours a day, seven days a week. These EDs bill using revenue code 450 and applicable CPT® codes;

(ii) A freestanding type “B” ED must have operations and staffing equivalent to a licensed ED, be physically located inside a hospital, and meet Emergency Medical Treatment and Active Labor Act regulations. All type “B” outpatient ED visits must be billed using revenue code 456 with level of care HCPCS codes G0380-G0384, even though the facility may not be open 24 hours a day, seven days a week.

Freestanding EDs Not Located in a Hospital

Freestanding EDs (FRED) not located inside a hospital cannot bill for a facility fee. Charges must be billed under the FRED's physical location and National Provider Identifier (NPI). The FRED may be associated with the hospital network, but it must be physically located in the hospital for the facility fees to be reimbursed. To avoid overpayment, regardless of if the FRED is associated with a hospital located elsewhere, all bills need to include the correct physical location and NPI.

Although these classifications prevent FREDs outside a hospital from billing a facility fee, the FRED may bill the technical components of the procedure codes. For example, if an X-ray is provided at the FRED, then the code needs to be billed with a -TC modifier to be paid accurately.  

The billing form must include the accurate location and NPI. A CMS1500 shall be used by all providers billing for professional services unless the provider meets the definitions found in Rule 16-2. Hospital-based ambulance and air services and other providers, such as hospital-based ambulatory surgery centers, shall bill for hospital or facility services on a UB-04.

Resource:

Colorado Division of Workers’ Compensation Rules 16 & 18

Colorado Department of Public Health & Environment (CDPHE), facility type search


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