Top 10 Differences Between Professional and Facility Medical Billing

As a medical billing expert, it’s important to understand the key differences between professional and facility billing.

1. Definition: Professional billing refers to billing for services provided by individual healthcare providers such as physicians and nurse practitioners. Facility billing, on the other hand, refers to billing for services provided in a hospital or other healthcare facility.
2. Billing Codes: Professional billing uses Current Procedural Terminology (CPT) codes to describe the services provided. Facility billing uses Healthcare Common Procedure Coding System (HCPCS) codes for billing.
3. Billing Forms: Professional billing uses a CMS-1500 form to submit claims. Facility billing uses a UB-04 form to submit claims.
4. Payment Rates: Medicare and other payers generally pay higher rates for facility services compared to professional services. This is because facility services include additional costs such as overhead, equipment, and staff.
5. Coding Guidelines: Facility billing uses a different set of coding guidelines than professional billing. For example, facility coding guidelines include codes for room and board, while professional coding guidelines do not.
6. Time of Service: Professional billing is typically performed at the time of service, while facility billing may be delayed until after the patient is discharged.
7. Claims Denials: Professional billing claims are more likely to be denied due to coding errors or lack of documentation, while facility billing claims are more likely to be denied due to medical necessity or other complex issues.
8. Revenue Cycle: The revenue cycle for professional billing is generally shorter than the revenue cycle for facility billing. This is because professional billing is typically paid faster and has fewer steps in the billing process.
9. Billing Staff: Professional billing may be handled by the healthcare provider or a dedicated billing staff member. Facility billing is usually handled by a team of billing specialists.
10. Compliance: Both professional and facility billing must comply with complex regulations such as HIPAA and the Affordable Care Act. However, facility billing may have additional compliance requirements due to the size and complexity of the organization.

By understanding these key differences between professional and facility billing, you can ensure that your medical billing processes are efficient, accurate, and compliant.

Call today to learn how Optimal Billing Solutions can help your medical or professional business by calling us at (855) 963-7800

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