When is a facility fee allowed/not allowed?
Outpatient health care services provided at hospital-based facilities located off-site from hospital campuses are treated differently than health care services located on a hospital campus.
Let’s start with hospital-based facilities located off-site from hospital campuses. For these facilities, Connecticut law prohibits hospitals, health systems and hospital-based facilities from collecting facility fees for outpatient health care services that use a CPT E/M code or assessment and management (CPT A/M) code when such services are provided at such a facility. Healthcare providers assign these codes to visits and services that involve evaluating and managing patient health. Hospitals, health systems and hospital-based facilities also cannot collect facility fees for outpatient services provided at such facilities when a patient is uninsured that are greater than the Medicare facility fee rate. However, they can collect facility fees for outpatient healthcare services provided at freestanding emergency departments.
As far as services provided on hospital campuses go, since July 1, 2024, Connecticut law has generally prohibited hospitals, health systems from collecting a facility fee for outpatient healthcare services that use CPT E/M or CPT A/M codes. However, they can collect facility fees for outpatient services provided in an emergency department located on a hospital campus, as well as for observation stays on a hospital campus, or when billing for the following services: wound care, orthopedics, anticoagulation, oncology, obstetrics, and solid organ transplant.
Facility fees for outpatient CPT E/M and CPT A/M coded services are also permitted if your health insurance plan’s contract with the health care provider allows them and was in effect on July 1, 2024. The fees will be permitted until the contract either expires, is renewed, or is amended, whichever occurs earliest.