Neurology & Pain Management Coding Alert

Watch for tricky situations, such as whether you can really report a mobile unit.

Physicians can administer sleep studies in several different places of service, which sometimes can confuse coders who aren’t sure of location distinctions or don’t know whether to report services from a facility or provider perspective.

Scenario: One of our subscribers asked: “We have a new physician reading sleep studies and are not sure what place of service to code for two scenarios – sleep lab in a hospital setting and an independent sleep lab.”

Read on for tips on distinguishing one place of service (POS) from another.

POS 11, Physician Office

Place of service 11 (Office) is simple to distinguish. Report this POS designation when you have a sleep lab in your office.

Tip: Physicians who provide sleep study services in their offices or freestanding sleep centers bill for the global service – both the technical component for performing the study and diagnostic study code such as 95810 (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist) without any modifiers. 

POS 21 or 22, Inpatient or Outpatient

Switch to POS 21 (Inpatient hospital) or 22 (Outpatient hospital) when your physician interprets studies in a hospital-based sleep center or freestanding location.

Coding: The facility will bill for performing the diagnostic study itself, and you’ll bill for the physician’s interpretation. Append modifier 26 (Professional component) to indicate the bill is only for the professional work.

POS 49, Independent Clinic

Sometimes physicians own a freestanding clinic with other physicians seeing patients and providing services.

Coding: The owner physician is now billing services from the facility viewpoint because he’s reporting services that other providers offered in his facility. Submit the correct sleep study code and append modifier TC (Technical component). Modifier TC indicates that you’re billing for the equipment related facility expenses, but not the physician work itself.

Alternative: A physician can still conduct studies on a patient even if he owns the facility. In that situation, you would submit two claims for the service, because you’re representing two separate entities. Bill the physician’s service with the appropriate sleep study code and append modifier 26 and the location where the professional interpretation was performed. Then bill the service for the sleep lab with the technical component (modifier TC) and POS 49.

POS 15, Mobile Unit

POS 15 (Mobile unit) indicates a facility/unit that moves from place to place and is equipped to provide preventive, screening, diagnostic, and/or treatment services.

Heads up: POS 15 might not always apply to studies in a mobile unit, depending on the circumstances. According to the April 2013 CMS MedLearn Matters Bulletin: “…When services are furnished in a mobile unit, they are often provided to serve an entity for which another POS code exists. For example, a mobile unit may be sent to a physician’s office or a SNF (skilled nursing facility). If the mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity. However, if the mobile unit is not serving an entity which could be described by an existing POS code, the providers are to use the Mobile Unit POS code 15. Medicare will apply the non-facility rate to payments for services designated as being furnished in POS code 15 and apply the appropriate facility or non-facility rate for the POS code designated when a code other than the mobile unit code is indicated…”.

To read the entire bulletin, visit http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7631.pdf.

POS 12, Home

POS 12 (Home) is defined in CPT^® as a location other than a hospital or other facility where the patient receives care in a private residence.

You can find yourself report POS 12 for unattended sleep study codes or some Medicare codes:

• 95800 – Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time
• 95801 – … minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone)
• 95806 – Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement)
• G0398 – Home sleep study test (HST) with Type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation
• G0399 – Home sleep study test (HST) with Type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate, and 1 oxygen saturation
• G0400 – Home sleep test (HST) with Type IV portable monitor, unattended; minimum of 3 channels.

Coding tip: Remember studies in these locations are not billed as a global service on a single line item since the technical component/place of service (home) will differ from where the professional component took place (where the physician interpreted the results).