Wiki Coding ultrasounds done at a Nursing or assisted living facilty

AmBaseer

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I work for a portable Xray/ultrasound provider. We service mainly residents of assisted living or nursing facility and also home bound patients. So we bill the CPT codes with place of service codes 12 , 13 or 32 . We never have any issue with Medicare billing in this manner, but the advantage plans like Aetna and Blue Cross, have been denying claims saying "not reimbursable when done at this place of service". They say the facility itself should bill them. I've explained that we transport the equipment to the facility/home and set it up and then do the exam and our doctors read and interpret the report so we bill the global code without modifier, but they still deny it. Some like Humana will pay it if we send the claim as two claims- one with TC and one with 26 modifier , but Blue Cross pays only the 26 and says the facility should bill the TC. Someone suggested using POS 15 and we did get a couple paid with that but our administrator doesn't want continue using that as his understanding of mobile unit is that the equipment is fixed in a vehicle, like a trailer and the exam is done inside that vehicle/unit and not actually in the patient's home or room in the facility.
I'm a complete loss for what to do. Is there any other way to code these? I'd appreciate any advice, and your thoughts on this issue.
 
I would investigate the legality of entering into a contract with the facility for them to purchase the services from you, then they can bill it.
 
For assisted living, I don't think the facility is required to provide the services. Same for home bound patients, since there is no facility.
For nursing homes (or rehab), absolutely the facility should be providing the services and is part of their bundled payment if they are in a Part A covered stay. You may bill the -26 to the carrier (it's a carve out). The -TC needs to be billed to the nursing home. You should have a written agreement in place that they will pay you for these services, and timely. Whenever we happen to do a sonogram in office on a patient who is in a nursing home or rehab, I think maybe 2% of the time the facility ever paid us for the -TC portion. Here's a good resource for services billable outside SNF payment: https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling
Or as Sharon suggested, look into a contract with the facility for the full service.
 
For assisted living, I don't think the facility is required to provide the services. Same for home bound patients, since there is no facility.
For nursing homes (or rehab), absolutely the facility should be providing the services and is part of their bundled payment if they are in a Part A covered stay. You may bill the -26 to the carrier (it's a carve out). The -TC needs to be billed to the nursing home. You should have a written agreement in place that they will pay you for these services, and timely. Whenever we happen to do a sonogram in office on a patient who is in a nursing home or rehab, I think maybe 2% of the time the facility ever paid us for the -TC portion. Here's a good resource for services billable outside SNF payment: https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling
Or as Sharon suggested, look into a contract with the facility for the full service.
The skilled nursing facilities are not an issue, thankfully (POS 31). The issues are with home (POS 12), saying "not reimbursable at this place of service " and with assisted living facilities (POS 13) they say - TC should be billed by facility. I really don't know how else to explain to their representatives. I've tried faxing appeals for individual claims and most of those will return as "original decision upheld".
Regarding a contract with the facility, I will advice our admin to look into the legalities of it, but since there are several that we service I don't know how feasible that would be.
 
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