Place of service 57 versus 11

jerseygirl66

Networker
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45
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0
Hi all,

I'm hoping someone can point to a source of reference. When is place of service 57 (Non-residential Substance Abuse Treatment Facility) versus place of service 11 (office) for substance abuse?

My new client has some claims that were posted to place of service 11, CPT H2036 and were processed with a copay. Same patient, same CPT, claim was posted with place of service 57 and the claims went to deductible. Insurance has said it was processed to deductible due to place of service (facility). I understand that some plans have higher deductibles when a facility setting is used versus an office setting.

Would it be inappropriate to bill claims under place of service 11? This is a freestanding office, not related to a hospital in any way.

Thanks in advance for any insight.
 

Chelle-Lynn

True Blue
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729
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Modesto, CA
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Place of Service 57
A location which provides treatment for substance abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.

Place of Service 11
Location, other than a hospital, skilled nursing facility, military treatment facility, community health center, State or local public health clinic, or intermediate care facility, where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

Based on the code you are billing H2036 (Alcohol and/or other drug treatment program, per diem) it would seem that your client is indicating that they are substance abuse treatment facility and/or office. H2036 is normally considered rehabilitative service. You would need to determine if the service was medical in nature (medical exam, diagnosis, or treatment of an illness of injury) or if the services rendered meet the qualification of substance abuse facility (therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing).
 
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