A revised policy by the Center for Medicare and Medicaid Services (CMS) regarding place of service (POS) reporting on all medical claims scheduled to take effect April 1, 2013, may create confusion for some providers.
In response to Office of Inspector General (OIG) findings from 2002-2007 that many physicians and suppliers frequently submitted incorrect POS codes, which subsequently resulted in overpayments by CMS, the new policy was intended to clarify which POS code should be used when services are provided.
For most services, the guideline simply requires that the POS code chosen for box 24B on paper claim 1500 from among the CMS-maintained list should reflect the setting in which the beneficiary received the face-to-face setting, and then the address of that location should be entered in box 32.
The two exceptions to this rule come into play when the patient is a registered inpatient or outpatient of a hospital. In those cases, the POS chosen would reflect the setting for which the beneficiary is a registered patient, regardless of where the patient receives the face-to-face care.
While the rule seems simple enough, specific billing scenarios for procedures with separate technical and professional components create a complex web of POS codes (box 24B) versus service facility locations (box 32), not to mention multiple dates of service and possible non coverage of service.
CMS guidelines indicate that procedures with both technical and professional components can be billed globally only when the technical component of the procedure and the physician providing the professional component are furnished by the same physician or supplier entity AND are furnished within the same Medicare Physician Fee Schedule payment locality.
According to representatives from WPS Medicare, the J8 Medicare Administrative Contractor (MAC) covering Michigan and Indiana Parts A and B, in this case, payment locality means “actual location.” If the physician providing the professional component is not at the same physical address as the technical component in which the patient received the face-to-face service, then the service cannot be billed globally.
If the technical and professional components are billed separately, then the POS code of the face-to-face service setting is used in box 24B for both components, but the Service Facility Location Information in Box 32 will be different for each. For the technical component, Box 32 will contain the address of the face-to-face service, but for the professional component, Box 32 will contain the address of the setting where the physician made the interpretation, whether his office, his home, a hospital, etc.
If the physician performs the professional component in an infrequent location, such as a hotel, then he can report the service location where he most commonly practices. However, if a physician routinely provides interpretations from his home, for instance, then that setting will need to be enrolled with Medicare via PECOS.
What’s more, because payment is based on the MPFS payment locality indicated by the zip code in box 32, according to WPS Medicare representatives in a March 21, 2013, teleconference, providers will need to be enrolled with the MAC covering each payment locality in which they provide professional services. As well, those claims would need to be submitted to the appropriate MAC.
Additionally, the date of service (DOS) for technical and professional components of the same service may vary. According to WPS representatives, the DOS for the technical component should be the date of the face-to-face service. The DOS for the professional component, however, is the date the interpretation or reading was made.
This may cause some issues with eligibility and coverage if a beneficiary receives the technical component of a service in one month but for some reason the professional component is not completed until the following month (i.e. crossing over the last and first days of two months). If the beneficiary no longer has coverage, the physician providing the professional service will receive a denial. WPS officials also confirmed this information in the March 21 call.
For more information about the revised and clarified place of service coding instructions, including special guidance for other situations like mobile unit settings and walk-in retail health clinics, review the CMS “MLN Matters” MM7631 from December 14, 2012.
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