Wiki how to bill location?

[Stenglein]

We have a patient who is in a specialty hospital. The patient scheduled an appointment and was seen by one of our optometrists in an outpatient setting. No referral to our office was made by the specialty hospital and review of the hospital notes do not indicate the patient had an issue for a referral to be made. Medicare is denying payment as it should be billed under the hospital location, yet our optometrist would not be able to bill from that location. Would anyone have a suggestion for this scenario?

 

[CodingKing]

Medicare is referring to the place of service code. If a patient is registered inpatient, even if seen in place of service 11, the place of service code on the claim is 21. You will then also get the lower facility physician fee schedule rate.


Medicare Claims Processing Manual

Chapter 26, 10.5

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf

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). 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