Inpatient Facility Coding & Compliance Alert

Question: One of my coworkers heard that some Medicare rules have changed regarding whether face-to-face time can change a patient’s inpatient/outpatient status when a radiologist is involved. What is she talking about?

Maine Subscriber

Answer: Your coworker probably is referring to the situation when determining the proper place of service to list on the claim can be sometimes be tricky when you’re billing radiology’s interpretation and report. The good news is that new CMS guidance will set you straight.

The latest Medicare rule states that the POS code you put on the claim needs to reflect the "setting in which the beneficiary received the face-to-face service," according to MLN Matters MM7631. CMS has created exceptions to the rule, however, so be sure to read the rule in full and pay attention to each element.

The article indicates two exceptions to the rule that the face-to-face service location decides the POS.

Inpatient: If the patient is an inpatient of a hospital, then the POS will be the inpatient hospital POS 21 regardless of where the face-to-face visit occurs.

Outpatient: If the physician provides services to a hospital outpatient, "including in a provider-based department of that hospital," then the POS should be outpatient hospital POS 22, the MLN article states.

Note: This rule does not change the fact that an office is an office, however. If the physician has separately maintained office space on the hospital campus (space that meets the regulatory requirements to be considered an "office"), and the patient presents for an appointment at that office, services performed in that space will still be POS 11.