CMS New Rule for Place of Service Coding for Physician Professional Component in 2013

CMS New Rule for Place of Service Coding for Physician. Effective April 1, 2013 – CMS had released a new rule on Revised and Clarified

Place of Service (POS) Coding Instructions:

CMS New Rule for Place of Service Coding for Physician

Part of the Instructions are as follows (Source: MLN Matters Number MM7631 Related Change Request Number 7631)

“CR7631 establishes that for all services – with two (2) exceptions — paid under the MPFS, that the Place of Service code to be used by the physician and other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. Because a face-to-face encounter with a physician/practitioner is required for nearly all services paid under the MPFS and anesthesia services, this rule will apply to the overwhelming majority of MPFS services. In cases where the face-to-face requirement is obviated such as those when a physician/practitioner provides the PC/interpretation of a diagnostic test, from a distant site, the Place of Service code assigned by the physician /practitioner will be the setting in which the beneficiary received the (Technical Component (TC) of the service. For example: A beneficiary receives an MRI at an outpatient hospital near his/her home. The hospital submits a claim that would correspond to the TC portion of the MRI. The physician furnishes the PC portion of the beneficiary’s MRI from his/her office location – Place of Service Code 22 will be used on the physician’s claim for the PC to indicate that the beneficiary received the face-to-face portion of the MRI, the TC, at the outpatient hospital.”

There are two (2) exceptions to this face-to-face provision/rule in which the physician always uses the POS code where the beneficiary is receiving care as a registered inpatient or an outpatient of a hospital, regardless of where the beneficiary encounters the face-to-face service. The correct POS code assignment will be for that setting in which the beneficiary is receiving inpatient care or outpatient care from a hospital, including the inpatient hospital (Place of Service code 21) or the outpatient hospital (Place of Service code 22). In other words, reporting the inpatient hospital POS code 21 or the outpatient hospital POS code 22, is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient or an outpatient of a hospital respectively. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient (or hospital outpatient), the appropriate inpatient POS code (or appropriate outpatient POS code) may be reported consistent with the code list annotated in Pub. 100-04, Medicare

Claims Processing Manual, Chapter 26, Section 10.5. However, it is more important that the physician/practitioner report the POS consistent with the patient’s general inpatient or outpatient hospital status than the precise inpatient/ outpatient Place of Service code (in order to trigger the facility payment rate under the PFS). “The Medicare Claims Processing Manual” (Chapter 26) already requires this for physician services (and for certain independent laboratory services) provided to beneficiaries in the inpatient hospital and CR7631 clarifies this exception and extends it to beneficiaries of the outpatient hospital, as well.”

The list of settings where a physician’s services are paid at the facility rate include:
Inpatient Hospital (Place of Service Code 21);
Outpatient Hospital (Place of Service Code 22);
Emergency Room-Hospital (Place of Service Code 23);
Medicare-participating Ambulatory Surgical Center (ASC) for a Healthcare
Common Procedure Coding System (HCPCS) code included on the ASC
approved list of procedures (Place of Service Code 24);
Medicare-participating ASC for a procedure not on the ASC list of approved
procedures with dates of service on or after January 1, 2008. (POS code 24);
Military Treatment Facility (Place of Service Code 26);
Skilled Nursing Facility (SNF) for a Part A resident (Place of Service Code 31);
Hospice – for inpatient care (Place of Service Code 34);
Ambulance – Land (POS code 41);
Ambulance – Air or Water (POS code 42);
Inpatient Psychiatric Facility (POS code 51);
Psychiatric Facility — Partial Hospitalization (POS code 52);
Community Mental Health Center (POS code 53);
Psychiatric Residential Treatment Center (POS code 56); and
Comprehensive Inpatient Rehabilitation Facility (POS code 61).

Related Reading and References: 

MLN Matters Number MM7631 Related Change Request Number 7631

Chapter 26 – Completing and Processing Form CMS-1500 Data Set

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Author: Pinky Maniri

Ms. Pinky, as she is fondly called - is a Reputable Professional Consultant and Expert in Practice Administration, Medical Billing, Coding, Health Information Technology, Insurance Credentialing and Compliance for Physician Offices. Well-educated with a Degree in Computer Systems Engineering and a background in Clinical Nursing and Small Business Management. Her professional mission is to make sure her clients/physicians maximize reimbursement while they remain compliant with the current rules, changes, guidelines and policies. Read More About Ms. Pinky here and See what Other's say about her Expertise Testimonials

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