Coders and their Code sets
Understanding medical coding doesn’t have to be complex. Let’s break down the difference between facility and professional coding using an example.
Facility vs. Professional Coding: Simplified
Facility Coding:
What it includes: Think of facility coding as the stuff provided by hospitals/ASC or the facility. This could be medical supplies, equipment, or certain amenities they offer.
Example - Facility Supply Code (Starting with C): A common code like "C1713" might represent a specific type of implant or medical device used within a facility.
So they paid for it and they get to bill for it.
Professional Coding:
What it covers: This is about services offered by individual healthcare pros like doctors or therapists in their own offices or clinics.
Professional services can also be performed in the facility but the billing would be of a Professional service not a product they did not need to cover the cost for.
Some private offices and clinics do get to bill for products and supplies they purchase. They can bill an insurance payer like Medicare if they are approved to purchase and bill for those products.
Then you have certain products specifically identified as only billable by a facility.
So if you are coding and billing for it. Does the payer allow it?
Example - Professional Service Code: Let's take "99213" from the CPT codes, which would indicate a level 3 office visit with a physician .
Understanding the Facility Supply Code
Imagine a hospital uses a Cardiac Event recorder that is implantable. The code for this particular device or product may be "C1764." This code is specific to the supply or device used within the facility. Only the facility can bill for this because they're the ones providing or paying for it. A private doctor in their clinic couldn’t use this code to bill because they likely don’t provide that specific device themselves.
Bottom Line
The key thing to remember is that facility codes, especially supply codes (starting with C), are for things provided or used within facilities. Professional codes, like those in the CPT book and sometimes the HCPCS level II book, cover the services provided by individual healthcare professionals.
Physicians are always looking for a way to capture more reimbursement but they need to stay in their lane to get paid compliantly.
So, when it comes to coding, knowing who provides what and which code is meant for which setting is super important. It’s like using the right tool for the right job – in this case, the right code for the right service or supply in the right place!
