Although it may mean denials, stay compliant when reporting inpatient transports to outpatient settings.Michael D. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCCBe sure your place-of-service (POS) code matches the setting where the patient received the service (for face-to-face services), or the setting where the technical portion of the service was delivered (for non-face-to-face services, such as diagnostic test result interpretation). Although this may sound easy in theory, new Medicare guidance can make POS assignment tricky.In recent transmittal 2563, change request (CR) 7631, the Centers for Medicare & Medicaid Services (CMS) clarified guidance for assigning POS codes on Medicare claims. That guidance has posed new questions that should be addressed regarding these claims.One of those questions came to light through Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-P, when she used the following coding scenario to point out discrepancies when reporting in compliance to the new POS reporting rules:“An inpatient is transported to an outpatient provider office for an evaluation and management (E/M) service and a procedure. The patient is still a registered inpatient and will return to the hospital at the conclusion of the visit.
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Should the outpatient provider report his or her E/M service using the outpatient E/M codes (5) or can they use the subsequent inpatient E/M codes? Applying the new POS code reporting rule, where an outpatient E/M service is reported with POS 21 or 22, the service will be denied.” Here is the relevant language from transmittal 2563, effective Oct. 11, 2012:“In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or nonfacility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS code 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred.”And here is the specific provider instruction added to the Medicare Claims Processing Manual:Special Considerations for Services Furnished to Registered Inpatients“When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient, the appropriate inpatient POS code may be reported consistent with the code list annotated in this section (instead of POS 21).
I suspect carriers will reprogram their claims processing systems soon to deal with this payment problem, where it exists. Attempting to avoid the denial by reporting an inpatient E/M service that was not performed, especially where that code results in the physician obtaining additional reimbursement, is not recommended. Even if paid, the provider would have to disclose and refund the overpayment within 60 days, consistent with the reverse false claims provision of the False Claims Act and the draft implementing regulations. Miscoe, Esq., CPC, CASCC, CUC, CCPC, CPCO, CHCC, has a Bachelor of Science degree from the U.S. Military Academy, a Juris Doctorate degree from Concord Law School, is president of Practice Masters, Inc., and founding partner of Miscoe Health Law, LLC.
He is a past member of AAPC’s National Advisory Board and a current member of the Legal Advisory Board. He is admitted to the Bar in California and to practice law before the U.S. District Courts in the Southern District of California and the Western District of Pennsylvania. He has nearly 20 years of experience in health care coding and over 15 years as a coding and compliance expert testifying in civil and criminal cases. He is a national speaker and has been published in numerous national publications.
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