Overview

If your claims are being denied, it is important to make sure the information on your claims is correct. One of the billing issues identified by the government as problematic has to do with coding for the location where services have been provided. Recently, the Centers for Medicare and Medicaid Services (CMS) revised instructions for what Place of Service (POS) codes to use for your claims, and the changes went into effect on April 1, 2013.

These instructions, issued as a result of a report published by the Office of Inspector General (OIG) on improper coding practices by clinicians, are designed to reduce errors in POS coding. Specifically, they help clinicians determine how to assign POS codes when interpreting diagnostic tests outside of the office setting.

Under the new rule, POS codes must be assigned based on the setting in which the beneficiary receives the face-to-face service. Because most services include a face-to-face component, this rule applies to the overwhelming majority of services. Where there is no face-to-face requirement, such as where an interpretation of a diagnostic test is performed remotely, you should use the POS code for the setting in which the beneficiary received the test (also referred to as the technical component (TC)) of the test.

This determination is generally made easily when distinguishing between a hospital and physician’s office. However, it becomes much more complex when services are provided in the hospital because a determination will still need to be made as to whether the patient is being treated as an inpatient or outpatient. When reporting POS, CMS instructs providers to pay more attention to the patient’s general inpatient or outpatient hospital status, rather than the precise inpatient or outpatient code. That said, if you know that a determination has been made regarding inpatient or outpatient status, that is what should be reported.

Previously, CMS had instructed practitioners to use the two-digit POS code that described where they were physically located when rendering the service.

Example

A beneficiary receives a myocardial imaging study (78491) at an outpatient department of a hospital near their home. The hospital submits a claim that would correspond to the TC portion of the myocardial imaging study. The physician furnishes the PC portion of the patient’s myocardial imaging study from their office location. POS code 22 (outpatient hospital) should be used on the physician’s claim for the PC to indicate that the beneficiary received the TC, face-to-face portion of the study, at the outpatient hospital.

Resources

Chapter 12 - Physicians/Nonphysician Practitioners
20.4.2 - Site of Service Payment Differential
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Chapter 13 - Radiology Services and Other Diagnostic Procedures
150 - Place of Service (POS) Instructions for the Professional Component (PC or Interpretation) and the Technical Component (TC) of Diagnostic Tests
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c13.pdf

Chapter 26 - Completing and Processing Form CMS-1500 Data Set
10.4 - Items 14-33 - Provider of Service or Supplier Information
10.5 - Place of Service Codes (POS) and Definitions
10.6 - Carrier Instructions for Place of Service (POS) Codes
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf

CPT Book, Professional Edition
https://catalog.ama-assn.org/Catalog/;jsessionid=B5YR30KIWYEFQCWBGOJVX5Q?_requestid=113916

MLN Matters: MM7631
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7631.pdf

OIG Report:
http://oig.hhs.gov/oas/reports/region10/11000513.asp

POS Code

POS Name

POS Description

04

Homeless Shelter

A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients

11

Office

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

12

Home

Location, other than a hospital or other facility, where the patient receives care in a private residence

13

Assisted Living Facility

Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, seven days a week, with the capacity to deliver or arrange for services including some health care and other services

14

Group Home

A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services

20

Urgent Care Facility

Location, distinct from a hospital emergency department, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention

21

Inpatient Hospital

A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions

22

Outpatient Hospital

A portion of a hospital that provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization

23

Emergency Room - Hospital

A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided

24

Ambulatory Surgical Center

A freestanding facility, other than a physicians’ office, where surgical and diagnostic services are provided on an ambulatory basis


For the complete list of Place-of-Service Codes for Professional Claims, see the current year Current Procedural Terminology (CPT) Book.

Coding questions and comments may be sent to coding@acc.org