Welcome back to my blog... The post for today revolves around Place of Service (POS) Codes. POS codes are one of the "first" things to check when claims are being denied. Below I've outlined what POS codes are, and how their usage can define success or failure when billing physician based, outpatient and inpatient claims. Enjoy!..........
The
Complexities of Place of Service (POS) Codes – Getting it correct up front!
Physicians
and providers practice in many different areas within a hospital setting. The trick to accurate physician and provider
coding/reimbursement requires knowledge and understanding of the Place of
Service Codes also known as POS codes. Coders should be diligent in determining
the correct POS code up front. The place
of service will be the determining factor for physician/care provider E&M
services to be coded or billed. The POS
is also a factor for facility codes to be coded and billed. In some circumstances, the hospital and the
provider may submit conflicting information if the claim is not coded with the
correct POS up fron. The ramification of
an incorrectly coded claim is the possibility of an inappropriate or incorrect
reimbursement to the provider or facility. In reviewing documentation prior to
coding, the coder should consider: . :
a) The correct “place of service” where the evaluation of the
patient took place,(such as in the Labor and Delivery, Radiology, or the Emergency
room)
b) The hospital/facility licensure of the area within the
facility that services were rendered (i.e. an area such as an outpatient office
–type that provides physician/provider based services within a hospital
setting.)
c) the type of service provided by the physician or care provider.
(i.e. evaluation/management, surgery, critical care, infusion, rehabilitation)….
The
Centers for Medicare/Medicaid services (also known as CMS) and the American
Medical Association (also known as the AMA) have developed a specific set of POS
codes dedicated to the designation of where medical services have been provided
for a patient. These codes are standardized
and have specific licensure for facilities associated with them. These codes are known as “Place of Service
Codes”. The most common areas where a physician
or care provider may be providing services are:
§
Inpatient Hospital Care Area
o Place of
service code = 21
§
Definition: A
facility, other than psychiatric, which primarily provides diagnostic,
therapeutic (both surgical and non-surgical), and rehabilitation services by,
or under, the supervision of physicians to patients admitted for a variety of medical
conditions.
§
Emergency Department Care Area
o Place of
service code = 23
§
Definition: A
portion of a hospital where emergency diagnosis and Hospital treatment of
illness or injury is provided
§
Outpatient Hospital Care Area ( or Observation – short stay)
o Place of
Service code = 22
§
Definition: A
portion of a hospital which provides diagnostic, therapeutic (both surgical and
non-surgical), and rehabilitation services to sick or injured persons who do
not require hospitalization or institutionalization.
§
Provider Office (to include provider based services that
occur within a hospital setting)
o Place of
service code = 11
§
Definition:
Location, other than a hospital, skilled nursing facility (SNF),
military treatment facility, community health center, State or local public
health clinic, or intermediate care facility (ICF), where the health
professional routinely provides health examinations, diagnosis, and treatment
of illness or injury on an ambulatory basis.
§
Urgent Care facility
o Place of
service code = 20
§
Definition: A
location, distinct from a hospital emergency room, an office, or a clinic,
whose purpose is to diagnose and treat illness or injury for unscheduled,
ambulatory patients seeking immediate medical attention.
Each
of the areas denoted above, are designated a specific “Place of Service” code
by CMS and the American Medical Association. .This complete listing can be found
in the CPT4 manual. The hospital or
facility also must have specific state and federal licensure established within
these areas for physicians and care providers to render treatment. Although these areas are all under the same
“roof” of the hospital/facility, these service areas are considered “separately
identifiable” and the billing of the provider’s services must correspond and be
reported correctly when billing the medical claim.
Below
are examples of different case scenarios that commonly occur in an OB/GYN
hospitalists’ job scope and function.
The brief case examples below give a glimpse of how the importance of the
POS code and its relationship to documentation and reimbursement.
Case Scenario #1: Patti is a 23 week gravida 1 para 0
presenting to L&D with diarrhea and malaise. Patient is evaluated over the
course of 30 minutes and discharged back to home with a diagnosis of viral
gastroenteritis in addition to the pregnancy.
This service would be coded with a “place of service” code of 22 - Outpatient hospital services – Evaluation and
management codes 99201-99215
Case Scenario #2 Patti is a 23 week
gravida 1 para 0 presenting to L&D with diarrhea and malaise. Patient is
evaluated over the course of 7 hours and 30 minutes. During the course of care, patient received
IV hydration and discharged back to home with a diagnosis of viral
gastroenteritis in addition to the pregnancy.
The facility and the physician determined the patient needed full
observation status services and was admitted to L&D as observation
care. This service would be coded with a
“place of service” code of 22 -
Outpatient hospital services,
E&M services for the physician/provider would be In/out same day
hospital service codes of 99234 – 99236.
The Facility would be able to bill for the room, and any associated
ancillary services such as the IV hydration and any medications that were included
in the hydration.
Case Scenario #3: Patti is a 23 week gravida 1 para 0,
presenting to L&D with decreased fetal movement and abnormal bleeding from
the vaginal area. Patient is evaluated
over the course of 60 minutes, and determined that the patient has a possible
placental abruption. The orders are then
sent that the patient will be “admitted” as an inpatient. Dr. Stamps then documents an
H&P/admission and a bed is secured for the patient in the inpatient
area of L&D. This service would be
coded with a “place of service” code of 21.
The E&M services billable by Dr. Stamps would be the Inpatient
Admission codes of 99221 – 99223.
Case Scenario #4: Dr. Stamps is called to the Emergency room to
see patient Patti, a 23 week gravida 1 para 0, who was a passenger in a motor
vehicle accident and currently being evaluated by the Emergency department for
neck pain. Dr. Stamps was called down to
the ED to evaluate the patient, as she is 23 weeks pregnant. Dr. Stamps does a full evaluation of the patient
in the ED area and denotes that Patti has a mild abdominal contusion from the
seat belt restraint, but no other major concerning “pregnancy related”
issues. This service would be coded with
a “place of service” code of 23. The E&M services billable by Dr. Stamps
would be the Emergency Department codes of 99281 – 99285
In addition, the 2012 OIG work plan, has targeted three POS codes as potential areas of audit, with the “risk factor” of inappropriate reimbursement to either the physician/provider office, or the facility where the services took place.
·
POS code 11
(offices),
·
POS code 21
(hospital inpatient departments), and
·
POS code 22
(hospital outpatient departments, such as provider-based entities).
Compliance for POS errors is difficult, as
the provider may submit codes for physician based services well ahead of the
facility. If the facility has “changed”
the POS code and not notified the provider office, the two claims submitted
(the provider claim and the facility claim) will not “match”, and thus a
red-flag may go up that these claims need to be reviewed by the 3rd
party payers or insurance carriers.
For coders, there seems to
be an “under-education” and misunderstanding of POS codes. Not only do coders not have a good grasp of
the importance of POS codes, but physicians and providers also do not
understand them.
In the nuts and bolts world
of the coder, the POS code(s) should be one of the first areas looked at before
determining the E&M billable services, or ancillary services to be coded
and billed. Coders need to be better
educated in understanding the importance of the POS codes, and the direct relationship
and impact on the reimbursement for providers and the facilities they work in.
For
a full listing and definition of place of service codes, and their appropriate
usage, the listing and definitions of POS codes found in the current CPT4
manual. Coders and also find more
specific Medicare/Medicaid requirements for correct POS assignment and
documentation at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2282CP.pdf
and
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf
