BILLING: HOSPITAL CHARGES

1. Diagnosis to Defer for CCS:

Certain diagnoses will typically require referral to the California Children's Services (CCS) program for further handling. Sutter usually requests CCS for these conditions. These diagnoses include:

  • COA (Coarctation of the Aorta)
  • TGA (Transposition of the Great Arteries)
  • HLHS (Hypoplastic Left Heart Syndrome)
  • AV Canal (Atrioventricular Canal Defect)
  • TOF (Tetralogy of Fallot)
  • Interruption of Aortic Arch

For newborns (when the mother is covered under an MCAL plan), the following conditions are typically deferred to CCS:

  • Respiratory Distress Syndrome
  • Extreme Prematurity
  • Hypertension
  • Cancer
  • Death

For toddlers (age 21+ with an MCAL plan), the following conditions require CCS referral:

  • Cancer
  • Diabetes
  • Gastroenterology issues
  • Cystic Fibrosis
  • Death

Additionally:

  • Cancer-related patients will be handled by Oncology/Hematology SAR (Special Authorization Request).
  • If CCS has been deleted or is taking too long, the next step is to call CCS County to check on the status.

2. Posting Charges in EPIC:

No Insurance Setup in EPIC: If insurance has not been set up in EPIC, follow these steps:

  1. Navigate to the patient's chart.
  2. Select MISC REPORT.
  3. Go to DEMO + INSURANCE.
  4. Verify eligibility and set up insurance in EPIC.

Hospital Charges should always include:

  • Admit Date and POS (Place of Service) code:
    • SMC: Sutter Medical Center
    • SDH: Sutter Davis Hospital
    • SRH: Sutter Roseville Hospital

Claim Information:

  1. Select Create New Claim Info Record.
  2. Enter the Name in the format: "ADMIT [Date] [Hospital Initial]".
  3. Input the Admit Start Date in the designated box labeled “Admit Date”.

3. Hospital Consult Codes:

These codes are used for different types of consultations and care:


  • 99291: Critical care code 5 years and older, only used when the patient is in NICU or PICU (please follow the table of content above) .
  • 99232 - 99233: Non-critical care codes for general inpatient care.
  • 99254 - 99255: Consultation codes for inpatient care (one time per admission, per doctor).
  • 99284: Emergency room visit, use POS code 23.

TEE and EKG Codes:

  • If both TEE (Transesophageal Echocardiogram) and EKG are done the same day, bill for the TEE only. Always check whether an EKG was done in conjunction with a TEE.

    • MCAL plans: Use code 93318 (Mod 26) for TEE.

      Commercial plans: Use one of these codes for TEE:

      • 93317
      • 93325
      • 93320 (All with Mod 26).

4. Referring Provider & Charge Submission:

  • Change Referring Provider to either:
    • H&P Admitting Physician or
    • Ordering Physician (depends on the situation).
  • Check the ECHO Date (the date the echo was ordered, not the date it was read). Use the echo order date to ensure accurate billing.
  • After confirming, submit the charge.

5. Repeat Procedure Modifiers:

  • When a procedure is repeated by the same provider on the same day for MCAL plans, use Mod 99.

    In the Procedure Comment, note:

    • “LINES [ ] WITH MOD 99 IS EQUAL TO MOD 26 + 76.”
    • This helps track the combination of Mod 26 and Mod 76 for billing purposes.

6. Newborns and Medi-Cal/CCS Insurance:

  • Medi-Cal, CCS, BC MCAL, CHW, NIVANO, IMPERIAL: Newborns should always be set as "Self (Subscriber)", even if it is the mother's insurance.

    If a newborn is eligible for CCS but has not yet achieved Medi-Cal eligibility for the month, proceed with:

    • CCS/SAR using the mother’s ID number. On line 1 comment line ( BOX 19 Newborn infant using mother's ID)

    • Once the newborn has Medi-Cal eligibility, change the insurance to the newborn’s own ID number.


Review and revised by : DP