# SNF pt came for an office visit.. MCR is taking back money



## amberlarsen820 (Jan 14, 2015)

A SNF pt came into our office for a visit. (I work for nephrologists.) We submitted the claim to Medicare for an office visit with Place Of Service 11 (Office). Medicare originally paid, but is now requesting the money back.

In our office, we have found instructions on WHO to bill, and it states we should bill Medicare part B. A coworker called Medicare, and they stated that this was correct, but we are using the wrong code, and Medicare has a list of codes on their website that are supposed to be used for consolidated billing.

Can anyone direct me to this list of codes? I have been searching for a good 20 minutes now with no luck. I have found one list, but it lists the office codes that we bill! 

Any help you can give me would be greatly appreciated! Thanks!


----------



## teresabug (Jan 14, 2015)

this sounds really crazy but this is what I was told: if a pt is under a part A SNF stay with MCR, and they come to your dr's physical office to be seen, in order for the claim to pay, you have to bill POS 32 for SNF and not 11, because Meidcare has the patient listed as a resident of a SNF and not their personal "home".
Also, consolidated billing means that certain procedures/care get paid by Medicare part A directly to the SNF. Like chemotherapy drug costs etc... if your dr is simply providing E/M care he should be reimbursed for this. I think theres an article on cms.hhs.gov - try doing a search for E/M POS for SNF's.


----------



## dclark7 (Jan 14, 2015)

What codes did you use?  Consolidated billing only applies to certain procedures not physician professional services.  POS 11 is correct if you saw the patient in the office and you should be billing with 99201-99205, 99212-99215 codes.  If you did any x-rays in the office they would be split into professional and technical with the technical (modifier TC) billed to the nursing home and the professional (modifier 26) billed to Medicare Part B.


----------



## amberlarsen820 (Jan 14, 2015)

I have actually done both of those. Medicare doesn't like any of them! I have found this on the website:

http://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2015-Part-B-MAC-Update.html

If you open up the first link at the bottom, (Part A Stay - Physician Services) it has a list of codes to bill Medicare Part B. The office codes are listed under this!!! I cannot find anything else that says otherwise on Medicare's website. We just might have to call again....

Thanks for all the help. Anyone else have any insight?


----------



## dclark7 (Jan 14, 2015)

Is the patient enrolled in a hospice program at the SNF?  If so then you would need a modifier on the office visit, either GV (attending physician not employed or paid under arrangement by the patient's hospice provider) or GW (Service not related to the hospice patient's terminal condition).

 If not, double check the reason for the denial, maybe there's something that got missed when looking at the EOB.


----------



## ollielooya (Jan 14, 2015)

*billing SNF*

Yes, we have done as Teresa has done.  Patient seen resided at a Part A SNF and presented for a prolia injection.  For the procedure we billed MCR with POS 11, received payment for the admin injection but the prolia medication was not.  The expensive medication had to be billed to the nursing home per consolidated billing rules, and after almost a year of followup and going beyond due dligience the practice was finally paid.  It was an arduous pursuit to say the least!


----------



## mitchellde (Jan 15, 2015)

ollielooya said:


> Yes, we have done as Teresa has done.  Patient seen resided at a Part A SNF and presented for a prolia injection.  For the procedure we billed MCR with POS 11, received payment for the admin injection but the prolia medication was not.  The expensive medication had to be billed to the nursing home per consolidated billing rules, and after almost a year of followup and going beyond due dligience the practice was finally paid.  It was an arduous pursuit to say the least!



Medicare states that the POS is to be the same as where the patient is registered. So if the patient is registered as a SNF patient and goes to the physician office for a visit the POS used by the provider is the SNF POS.


----------



## dclark7 (Jan 15, 2015)

According to the Medicare Claims Processing Manual, Chapter 26, Section 10.6 and clarified in CR 7631, MLN #7631, dated 4/1/13, The place of service billed is to reflect the place of service where the face to face services were rendered with two exceptions.  These exceptions are a registered hospital inpatient (POS 21) and a registered hospital outpatient (POS 22).


----------



## ollielooya (Jan 15, 2015)

Debra and Doreen, thanks for posting this.  Always great to have the official documentation, and Debra, I thought you might post to my reply because I had seen you answer this question before about the proper POS to bill.  Thanks for verification to not only myself but to the original poster!


----------



## amberlarsen820 (Jan 21, 2015)

I guess we are going to have to appeal. I have used POS for the SNF -- MCR said that the patient was not seen at the SNF, we have to use POS 11 for office.


I have gone around and around with this...I wish MCR would make up their mind!


----------



## amberlarsen820 (Jan 21, 2015)

*The answer!*

I have the answer finally! After calling Medicare AGAIN, we have discovered that Medicare gave us incorrect information the first time.

Per CMS, you bill Part B for the office visit (using an office visit code -- because these are not included in the consolidated billing for SNF) and use POS 11 because that is where the patient was seen!

Side Note -- Our office also has a vascular center with the same tax ID number...and this patient ALSO had a vascular procedure the same day. Medicare is taking back the drugs that were billed (which should be billed to the SNF.)

Long story short -- we get to keep the money for the office visit because it was processed and paid correctly.


----------



## ollielooya (Jan 21, 2015)

Amber, thank you for coming back to the forum to post how you are dealing with the problem and finding the resolution!


----------

