Practice Management Alert

Don't confuse nursing facilities and skilled nursing facilities

Question: I-ve been getting claim rejections that indicate the only reason for the rejection is the place of service. How can I ensure that I-m choosing the right POS numbers for my claims?

Answer:You need one place-of-service (POS) code for every claim. But if you don't choose the correct code, not only are you potentially losing money, but you-re also risking denial of your entire claim.

Choosing the correct POS code is important to every claim and makes a difference in the amount you-re reimbursed and whether your claim is paid or denied, says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, TCN senior orthopedic coder and compliance auditor and an executive officer of the AAPC National Advisory Board.

Tip: You need a separate claim for each POS. This means that if your physician services multiple points of service, you need to create a new claim for each POS.

Read on: Steer clear of disaster with our experts- advice on billers- most pressing -- and confusing -- POS issues.

Decide Between Hospital and Office

If your office is part of a hospital, determining which POS code applies may vary -depending on the financial setup between the physician and hospital,- Grady says. -CMS does have some other rules for provider-based billing, in which both physician and hospital bill for the E/M code.- The hospital bills a facility portion, and the physician bills a professional portion. In the CMS database, many codes are split with a facility value and nonfacility value.

Helpful: If your office is on hospital grounds, don't report POS 11 (Office) or POS 22 (Outpatient hospital) until you ask yourself the following question: Is the provider paying fair market rent for the facility? If so, consider the space an office and select POS 11.

If you aren't paying fair market rent, choose POS 22. Reason: When you aren't paying for use of the facility, you shouldn't receive any extra reimbursement for the cost of renting an office. You only earn the higher non-facility fee (called for by POS 11) if you-re paying rent and incurring the other costs of running a practice.

Payment differences: -POS can change your reimbursement,- says Pamela Biffle, CPC, CCS-P, ACS-DE, a PMCC instructor and director of operations/senior instructor for CRN Institute in Salt Lake City, Utah. -For example, office versus hospital -- the hospital [facility- based] fees will be lower. Also, there are some services that are only reimbursed when performed in certain POS.-

Distinguish Between Nursing Facility Types

If you are billing Part B for services you provide to patients in nursing facilities, there's a lot of room for error when you have to decide among POS 31 (Skilled nursing facility), 32 (Nursing facility), and 33 (Custodial care facility used for assisted living).

The key: Look at the level of care the facility is providing, says Heather Hankins, office supervisor for Cranbrook Primary Care PLLC in High Point, N.C.

Best bet: Check with the facility you-re billing for. -The facilities should be able to provide you with their classifications,- Biffle says. -It doesn't really matter what they do if they are not classified for that level of service. Some facilities have different units with the different designations.- Other facilities can have a nursing facility patient in the same room as a skilled nursing facility patient, so facility designation is more a paperwork designation than a physical one.

A facility can have both skilled nursing and non-skilled nursing beds simultaneously.

- 31: You should use skilled nursing facility code 31 when your physician tests a patient who is in a skilled bed at the time of service. This means the patient has a medical condition that requires skilled nursing care, such as injections or ventilation.

Note: If a nursing facility brings a patient to your office, you should report POS code 11 (Office) on the claim form.

- 32: You should choose nursing facility POS code 32 if the patient is not on Part A Medicare but is instead on long-term care and receiving medical, nursing or rehabilitative services.

Because determining what type of bed the patient has can be difficult, you need to maintain close communication with the administrative or billing office in the nursing facility to determine whether the patient is in a skilled bed when a provider sees the patient there.

- 33: You would report POS code 33 for a custodial care facility (assisted living facility) -- a facility providing patients with personal assistance services (such as dispensing medications) on a long-term basis but which does not provide medical care. Patients are mobile in a custodial care facility, so be sure there is medical necessity for you to see a patient at the facility and not in your office.

Example: If a patient in the custodial facility has a hip fracture and is unable to go to your office, you would be able to see the patient at the custodial care facility.

Tip: -In the front of the CPT book, there are good descriptions of exactly what each place of service is,- Hankins says.

Stay tuned: Watch for an article on consolidated billing with SNFs in a future issue of Medical Office Billing & Collections Alert.