# ? -office visits/pt in a rehab facility



## RebeccaB

Hi Everybody,

Our practice has been getting Medicare denials for pt's we have seen in the office that are in an acute rehab facility. Medicare denial-The National Registry shows pt in a facility so denying our claim as location office.

Any help on these denials or where the Medicare guidelines for this billing can be found-We contacted the rehab facility & they have stated that they are not an SNF-

Any thoughts, ideas, suggestions would be most helpful

Thanks,Rebecca


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## nkorab

Our office encountered this same thing.  We found out that you have to bill the office visit with the POS and CPT codes for where the pt is residing. ( the rehab facility). Medicare then paid us.

If you perform a procedure, then you bill the facility.

Hope this helps.
Nancy


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## j.monday7814

I posted a similar thread in this forum and Billing/Reimbursement. I would never believe that Medicare would want the claim to reflect the POS of the acute setting that they are admitted to like an acute rehab facility or SNF. By submitting that POS you are telling Medicare that the patient was physically seen in that location and of course they will pay that claim because it could be valid. But since the patient was actually seen in the office then the only valid POS would be 11. Our recent discussion with a representative at our MAC told us that Medicare will never pay for a service billed with POS 11 if the patient is enrolled in an acute care facility and claims for E/Ms provided in the office should be sent to the SNF.


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## mitchellde

The transmittal actually states to use the POS of the setting where the payient is registered regardless of where the service is rendered.  So even if it is acute care inpatient you would use 21 not 11, but you the code for the visit appropriate to the setting so regular office visit levels with the POS for rehab facility, or inpatient, or nursing home.


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## j.monday7814

we tried that scenario, regular office visit code with POS for the rehab facility and the claim was still denied. Using the POS other than 11 in this situation would be inappropriate  and maybe even considered fraudulent. Medicare always wants to know exactly where the patient is when they receive their face-to-face service. Why would SNF be any different?


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## mitchellde

You should not use the word fraud without first checking to see.
Per the CMS manual page 24 of chapter 26.
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). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility.


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## j.monday7814

incorrectly reporting the POS can be interpreted as fraudulent, I'm sure you can understand that.

those guidelines don't refer to the situation we're discussing. in either case these claims do not get paid by Medicare and after calling them we were told that no matter how we submit our office visits they will not be paid by Medicare. if Medicare won't pay the claim then obviously it doesn't fit their guidelines correctly.


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## mitchellde

However to follow CMS instructions is not fraud. And yes this does applynto this scenario. It states you apply the POS for where the patient register regardless of where the face to face takes place.  If you look at the last sentence this includes patients in a SNk or Rehab facility.  It never states this will render reimbursement only that the services must be reported this way.  Reimbursement for patients in a SNF is an entirely different issue, but the service provided must first be correctly billed.  This means that an in office service provided to a patient that is registered in an inpatient setting, which includes SNF and rehab must be reported with the POS that equals the place where they are registered and not 11.  If you read the manual it goes on to state that use the office visit codes for new or established patient not the inpatient or nursing home codes.
This is NOT fraudulent reporting.


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## j.monday7814

> Reimbursement for patients in a SNF is an entirely different issue,



that was funny, so then how do we get paid for these claims? following your misinterpretation doesn't work because we interpreted it the same at first. we've also tried every other way we can imagine and nothing allows the claim to be paid. I'm open to ideas but I'm not going to make the claim look like the patient was seen in the SNF....how can Medicare tell the difference when we do see the patients in SNF vs when we see them in the office?

The claims processing manual does not go into details about using POS 11 for this situation.


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## mitchellde

j.monday7814 said:


> that was funny, so then how do we get paid for these claims? following your misinterpretation doesn't work because we interpreted it the same at first. we've also tried every other way we can imagine and nothing allows the claim to be paid. I'm open to ideas but I'm not going to make the claim look like the patient was seen in the SNF....how can Medicare tell the difference when we do see the patients in SNF vs when we see them in the office?
> 
> The claims processing manual does not go into details about using POS 11 for this situation.



I am NOT misinterpreting anything anything on this matter.  Medicare knows the difference because your POS is to reflect where the patient is registered as a patient, the address you use in Field 30 will be your office address.  If your patient is a patient in a registered inpatient setting, then Medicare ia already reimbursing for the place of service when they pay that facility.  You can only be paid for the physician service not the office portion since your provider could go to the inpatient setting and see the patient.  So the reimbursement is less than when you use the POS 11.  Now SNF is a little different since it depends on the particular circumstances, because in some cases you must bill the SNF for the reimbursement and not Medicare.  Just because you tried it correctly and it did not get paid does not mean it was incorrect POS.  There are many other reasons this could have denied, one of those being you must bill the SNF for the reimbursement.  
I found this information all in the claims processing manual.


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## BenCrocker

Trust me if anyone knows her stuff it's Debra. She's corrected me many times.


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## j.monday7814

> one of those being you must bill the SNF for the reimbursement.



that's exactly what I said earlier. Our MAC told us that we must bill the SNF for our office services. They told us that there is no way they will reimburse us for an office visit while a patient is admitted to a SNF. So, submitting any of the claims to Medicare is wrong and now we're going to start trying to send the claim to the SNF.

This level of detail is not in the claims processing manual. Thanks for not helping at all.


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## mitchellde

You are carving out sentences that suit your purpose without looking at the entire context. 
First my initial response was directed at the initial post in this thread which is a correct response, you then indicated this would be fraud.  I responded to you indicating this is not in fact fraud but the correct way to bill per the Medicare manual.  And so on.  Not all SNF patient encounters are billed to the SNF, only those that are subject to consolidated billing,  if it is not subject to consolidated billing the Medicare will reimburse for the office encounter provided you use the SNF POS and regular office visit levels.  Consolidated billing as well as using the correct POS is well covered in the Medicare manual.
I am sorry if you feel this is not helpful but I hope others find it enlightening.


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## solocoder

When the patient is in a skilled nursing facility, you have to bill the facility. Medicare pays the facility.  We have to do it all the time.


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## mitchellde

You bill the SNF only if the services provided fall under consolidated billing. E&M service does not fall under consolidated billing.  Check the Medicare instructions for this:
Consolidated billing covers the entire package of care that a resident would receive during a covered Medicare Part A stay. However, some categories of services have been excluded from consolidated billing because they are costly or require specialization. The following categories of services have been excluded from consolidated billing:

Physician's professional services;

Certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services;

Certain ambulance services, including transporting the beneficiary to the SNF initially, transporting from the SNF at the end of the stay (other than when involving transfer to another SNF), and transporting round-trip during the stay temporarily offsite to receive dialysis or certain types of intensive or emergency outpatient hospital services;

Erythropoietin for certain dialysis patients;

Certain chemotherapy drugs;

Certain chemotherapy administration services;

Radioisotope services; and

Customized prosthetic devices.
And from the federal register:
Professional physician services are not subject to consolidated billing, the physician or other licensed health care provider who provides evaluation and management services to an SNF resident bills for these services independently to Medicare Part B. Some CPT codes carry both a professional and a technical component. For instance, there are laboratory and radiology procedures that are split into a technical component, which accounts for the performance of a particular procedure described by CPT, and the interpretation of the procedures results. An SNF is responsible for the charges incurred by the technical aspect of a service, while the provider bills Medicare directly for the professional aspect. The provider then bills the SNF for the technical expense out of its per diem rate received from Medicare Part A.
Now this is why you bill with the SNF POS when the service provided is E&M.  Since an E&M has no technical component, the POS11 reimburses more to cover some overhead.  However when the patient is a registered inpatient such as a SNF then Medicare is already paying overhead to the SNF.  They will however pay the profession service.  That is why you use the SNF POS. The reimbursement will be less than the POS11.


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## jflynn124

I do these all the time, when you receive your denial (with correct pos 11) you just have to submit a re-determination request with notes showing that the dx your doc saw the pt for is not related to what the patient is in the rehab for. Don't stress people.


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## mitchellde

jflynn124 said:


> I do these all the time, when you receive your denial (with correct pos 11) you just have to submit a re-determination request with notes showing that the dx your doc saw the pt for is not related to what the patient is in the rehab for. Don't stress people.



Clearly Medicare instructions are that these are to billed with the rehab POS.  I do not understand what is so complicated.  It is clearly written in the instructions.  using POS 11 is obviously incorrect.  It does not matter that you appeal and are subsequently paid, it is still incorrect.  Please read the instruction I previously posted from the MCM.


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## j.monday7814

mitchellde said:


> Clearly Medicare instructions are that these are to billed with the rehab POS.  I do not understand what is so complicated.  It is clearly written in the instructions.  using POS 11 is obviously incorrect.  It does not matter that you appeal and are subsequently paid, it is still incorrect.  Please read the instruction I previously posted from the MCM.



Hopefully you're realizing that you've misinterpreted those guidelines by taking them out of context. This is another situation where you don't know how to apply the guidelines to real world coding.

We may have some slight differences with MAC guidelines which is why some groups can appeal to receive reimbursement and others (like myself) are still working out the solution while maintaining compliance. The goal is to get paid for services rendered while following all guidelines...using POS 11 for providing a service in the office is absolutely correct and I have not found any documentation to prove otherwise. Medicare always wants to know where the patient was at during a face-to-face encounter.


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## cheermom68

*guidelines*

I think we need to be careful about attacking the personal integrity of members that are willing to provide guidance to those asking questions.  Debra has always been very willing to give her time and knowledge on various forums.  
Debra and I have both provided the guidelines DIRECTLY OUT OF THE MEDICARE CLAIMS PROCESSING MANUAL  (no interpretation required)  related to this issue more than once on the other forum where this issue was discussed.  
LeeAnn


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## mitchellde

Thank you Lee Ann!  I am at a loss as to what more can be said.  There is no misinterpretation as the Medicare instruction is so very clear and plain English written.  also it is not taken out of context since the entire section has posted.  I will not agree to disagree.  I am stating the correct way to bill these claims.  Yes Medicare wants to know where the patient is, and the correct place is the inpatient setting, that is where they are registered as a patient.  Medicare would prefer your provider go to the patient, so when you have the patient brought to you then technically they are still in that inpatient setting, so they are not going to give you office setting reimbursement.


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## BenCrocker

> Medicare would prefer your provider go to the patient, so when you have the patient brought to you then technically they are still in that inpatient setting, so they are not going to give you office setting reimbursement.
> __________________
> 
> Debra A. Mitchell, MSPH, CPC-H



This makes so much more sense to me now. And it's clear to see why it has to be the way Medicare wants it the way they do.


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## ollielooya

*Observing from the sidelines*

Been watching this thread with extreme interest as this has popped up again for one of our doctors who has and is seeing patients from skilled nursing centers.  As a result, I'm pretty sure as to how to address the billing process  with our provider to supply the "fix" ward off denials.  In the past, they were split denials meaning, the EM was paid, but the procedure (usually diagnostic ultrasounds) were denied.  We rebilled MCR for the procedure for the professional component, (modifier 26) and the nursing institution for the TC component.  Sometimes the nursing homes can be quite slow in rendering payment, but persistence pays off.

Thanks for all the help and lively discussions.  There are many others out there who have read this thread and no doubt have found the information edifying and helpful.  Thank you, thank you!


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## catkinson80

*Debra is correct*

She hit it right on the nail. With these types of services you do have to bill the place of service of where the patient is housed at the moment. I have read other posts that she has responded to and you would be wise to follow what she is saying.


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## MaryMoore

*E & M Visit, While Beneficiary Is Inpatient*

E & M Visit, While Beneficiary Is Inpatient

Why do I have to bill an inpatient Evaluation and Management (E&M) service when the patient was brought to my office?

The Centers for Medicare & Medicaid Services (CMS)Internet Only Manual (IOM) Publication 100-04, Chapter 26, Section 10.5 states:

"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). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility."

In addition, CMS IOM Publication 100-04, Chapter 6, Section 80.4 states, "For example, if SNF inpatients are taken to the private office of a neurologist for necessary tests such as an encephalograph, the services are considered performed in the SNF for billing and payment."

Based on the IOM references, the appropriate POS code to use when seeing a patient classified as a hospital inpatient is 21. For a patient in a covered Part A stay in the SNF, the POS is 31. The physician should choose the procedure code for the correct category of E/M services.

If performing a procedure, verify if there are differences between Current Procedure Terminology (CPT) codes for an inpatient and outpatient procedure. For example, if performing a diagnostic procedure such as a chest X-ray, the provider would bill the technical only component to the facility for payment. The professional component would be submitted to the providers Contractor/MAC for payment. For an E/M service, providers should choose a code from the inpatient hospital or SNF category of services.

"https://wpshealth.custhelp.com/app/answers/detail/a_id/78/~/e-%26-m-visit,-while-beneficiary-is-inpatient"


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## Katherin1994

"When the patient is in a skilled nursing facility, you have to bill the facility. Medicare pays the facility.  We have to do it all the time."


Hi I'm an extern at my site and they have been allowing me to do AR. They have been billing Medicare part B, not knowing they are from a SNF, Medicare pays but then recoups the money. Now I have been asked to do some research so that I may help get these claims processed. I was informed that I was going to have to find two separate codes but as I am reading the threads on this topic, am I reopening  the claim under medicare and adding a POS modifier and billing the SNF with a TC modifier. Thank you in advanced literally finding this out would be a life safer for this billing company because they have been getting denials with all of their cardiovascular doctors.


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## mitchellde

you need to look up consolidated billing for SNF.  this will give you you so much good information.


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## tmarugg

*Thank you Debra*



mitchellde said:


> Thank you Lee Ann!  I am at a loss as to what more can be said.  There is no misinterpretation as the Medicare instruction is so very clear and plain English written.  also it is not taken out of context since the entire section has posted.  I will not agree to disagree.  I am stating the correct way to bill these claims.  Yes Medicare wants to know where the patient is, and the correct place is the inpatient setting, that is where they are registered as a patient.  *Medicare would prefer your provider go to the patient, so when you have the patient brought to you then technically they are still in that inpatient setting, so they are not going to give you office setting reimbursement*.



I've been on the hunt most of the morning for the answer to this very question.


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## angelarleta

Our office has had the same issue. We have billed the claims with the EM code and the POS 11. If we receive a denial we will appeal the claim with the medical records and if we can get it notes from the rehab facility stating the patient was transported to the physician office via ambulance/private car with the reason for the appointment.  I have had the claims pay using this approach but I almost always have to appeal.


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## mitchellde

again you must use the POS of where the patient is registered as a patient not POS 11.  you patient is a patient in an inpatient rehab facility, so that is the POS code you must use when the patient is brought over to your office.


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## vestutom

*office visit while patient is inpatient*



mitchellde said:


> again you must use the POS of where the patient is registered as a patient not POS 11.  you patient is a patient in an inpatient rehab facility, so that is the POS code you must use when the patient is brought over to your office.



I tried billing this way and my claim was denied for procedure code inconsistent with place of service code.  What am I doing wrong?  In this case, the patient was an Inpatient at a drug rehab facility.


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