Correct POS (Place of Service) Billing

tdfaircloth

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My company does professional billing for a physician's group that is insisting that we use POS 11 for a specific commercial insurance company when billing their charges because this commercial payer has written a policy specifically for them that says it is okay to bill with a POS 11 to them. But this physician's group wants us to use POS 22 for all other commercial insurance payers, medicaid and medicare payers for the same location. We do not believe this is appropriate. We found guidelines from CMS on POS but it does not address the duel POS setup this physician's group is requesting. Any advice would be appreciated.

Sincerly,
T Faircloth
 
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mitchellde

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My company does professional billing for a physician's group that is insisting that we use POS 11 for a specific commercial insurance company when billing their charges because this commercial payer has written a policy specifically for them that says it is okay to bill with a POS 11 to them. But this physician's group wants us to use POS 22 for all other commercial insurance payers, medicaid and medicare payers for the same location. We do not believe this is appropriate. We found guidelines from CMS on POS but it does not address the duel POS setup this physician's group is requesting. Any advice would be appreciated.

Sincerly,
T Faircloth

Your POS cannot change with payer. Your POS is based on how your office is set up or where the service was provided. If you are an independent physician office then you are an 11 and cannot be a 22 ever. However if you are owned by the hospital as an outpatient clinic then it will be a 22 always. The rate of reimbursement is different. However a payer cannot dictate which POS to bill with. However they can state where they will cover services for there patients. So what type of physician office are you billing for? And where was the patient when the service was rendered?
 

tdfaircloth

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Update

The services are being performed at a hospital owned office/clinic and we are using POS 22 for this location. I have the CMS guidelines that indicated the same as you stated but the Physicians group are insisting that the Commercial payer does not have to abide by the CMS guidelines. Could you point to any other industry guidelines concerning POS.

Thanks,
T Faircloth
 

mitchellde

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They do need to go by the rules of POS. The reimbursement is different based on the POS. You will be overpaid when you use 11. If you contact the payer they will be able to provide you with the information you seek.
 

thomas7331

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I've also encountered this situation in my work - some commercial payers do not recognize provider based status for outpatient clinics and do not have a fee schedule differential some services. If so, they will deny the facility fee and pay the full amount on the professional/1500 claim, and in this case they may want the 11 POS code as it would not affect payment but may affect what copay is charged. This usually applies just to E&M (revenue code 510 on the hospital claim) and other services would still be split between the hospital and professional claim and billed as an outpatient facility place of service, but you'd want to be clear on these requirements. If any payers require this, it should be carefully spelled out in writing either in their billing guidelines or in the provider's contract and you should be able to obtain this information and not have to rely on word of mouth guidance. I would absolutely not bill claims with an incorrect place of service without having something in writing from the payer.
 

ccollison

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Pos 22

We also had issues with provider based billing and the correct POS. Federal payors (Medicare, Medicaid, Tricare) recognize POS 22 or 19, but many commerical & BCBS do not. We had to get a letter from each carrier stating how they wanted our hospital owned locations to bill. It was very confusing to many carriers and quite a long process. Some patients got caught in the middle with higher copays/deductibles until the commercial carriers understood PBB.
C Collison, CPPM, CPC, CCC
 
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Similar issue

I work for an anatomic diagnostic lab. We are contracted with all carriers, including Medicare as office POS 11. We are being told to change the POS to 81 (independent lab) if the carrier denied claim for incorrect POS. My question is if we are contracted as 11 are we required to bill as 11? isn't this fraud to change POS to get reimbursement?
 

thomas7331

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Contracts are written agreements with the payers - if the contracts state that you are to bill a certain way, then to do otherwise would be a breach of contract, not fraud. But I would think it would be unusual for a payer contract to tell you what POS to use, and I don't think Medicare makes 'contracts' with providers that would give any exceptions to following standard regulations for billing services. Can you clarify what you mean?
 

Pam Brooks

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We had this issue a number of years ago, and since have documentation from one commercial payer that doesn't recognize office/outpatient E&M visits done in POS 22. They wanted our Cancer Center outpatient clinic billed as POS 11.

I threw a Tasmanian fit when the billing department asked us to do this and we even consulted with our legal folks, who advised us that if we were being asked by a payer to bill a POS that was different than what was considered correct coding, that we needed to get their specific instructions in writing, which we subsequently did (if they wanted me to let the claims go out with a place of service other than 22).

It's a major pain to have to manually change the POS to 11 for outpatient office visits within an outpatient hospital department, but since we're contracted with that payer and have agreed to bill according to their guidelines, we are expected to do so. So it does happen, but get it in writing.
 

mitchellde

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Is it possible that they really want the physician service billed on the UB-04 with the clinic facility charges using the revenue code for physician? I have come across this before.
 
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