Revenue Cycle Insider

Question: We know how we should bill when a patient is taken out of their skilled nursing facility (SNF) stay to be seen by our specialist in the office. We bill office visit codes using a place of service (POS) code 31 to indicate they are in an SNF stay, but lately we have had claims being denied, stating that, “the CPT^® code is inconsistent with the POS.”

I am trying to find something that proves this is the correct way to bill. The only way we can appeal this with the patient’s UnitedHealthcare (UHC) Medicare Advantage (MA) plan is to prove to them that Medicare prefers the visits billed this way. All I have found so far is information stating we need to bill with the POS, but it doesn’t say which specific CPT^® codes to use. How can we stop these claims from being denied?

Indiana Subscriber

Answer: Based on the situation described above, it sounds like one of the following scenarios may be occurring:

1. The POS and the codes you are using are not communicating with one another. If the patient is physically in an SNF during the visit, you will need to make sure you are using the SNF evaluation and management (E/M) codes along with POS 31 (Skilled nursing facility) to avoid a denial. Based on the denial reason on the claim, it sounds like you may be billing conventional new/established patient office visit E/M codes instead.

Try using codes from the 99304 (Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination…) to 99306 code set for initial care and look to the 99307 (Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination…) to 99310 (Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) code set for subsequent care of a patient to avoid future denials while billing with POS 31.

2. If the patient is physically removed from the SNF to see a physician in another setting, you will need to change the POS to match the facility they are being seen in. For example, if the patient is being seen in an office setting, you will bill using POS 11 (Office) and an appropriate E/M code from the 99202-99215 (Office or other outpatient visit …) code set for your claim.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC