Wiki Place of Service Question - Podiatry facility

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sjstark

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I have a question regarding place of service (POS) usage. We have a Podiatry facility we will bill for in NY. The facility will bill the facility claims for Medicare, Medicaid, and Medicaid Managed Care plans using a POS 22 (outpatient). We will bill for the professional claims using POS 22 as well. These claims are for E/M and procedural services. The question comes in when billing for commercial insurance plans which will only be billed under the professional claim. If we bill with a POS 22 for these insurance plans we will receive a reduced reimbursement if compared to the same services paid in an office setting. In turn, the facility will lose out on reimbursement because the facility will not bill for a portion of these claims.

It was suggested that we bill using a POS 11 (office) for all the commercial claims and use POS 22 for Medicaid, Medicare, and Medicaid Managed Care. Billing in this manner would get the commercial claims reimbursed the maximum allowed and the governmental claims for the correct professional portion only. Would it be appropriate to bill different place of service codes based on insurance plan? Any input would be greatly appreciated.

Thanks, Scott
 
Is this a Hospital-based facility, or a free-standing? If Hospital-based (which is the POS 22 per your claims), all their claims should be billed on a UB-04, not a CMS-1500, and there is no POS code on those claims.

The POS code on your physician claims communicates where the services were provided, in the doctors' private office (11) where he/she is responsible for all the staff/overhead, etc., or a hospital OP facility (22) where the facility is responsible for paying the ancillary staff, lights/overhead. To report that your provider provided services in POS 11 when in actuality it was a hospital-based facility is fraud. :eek:

The problem is with the hospital-based facility. They should be billign for their own services. Even if your physicians are getting the reduced reimbursement since they are not getting paid (nor should they) for the facilities resources, they are getting what they are LEGALLY and ETHICALLY entitled to.
 
Not part of a hospital system? If it is a free-standing ambulatory surgical center, it would be POS 24; an independent clinic "a location, not part of a hospital and not described by any other POS code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to OPs only," would a 49.

It is between your physicians and the facility, but I would never advise or suggest to anyone to report a POS code that is not accurate (which a POS 11 clearly would be inaccurate) without a signed agreement with the facility and/or appropriate payers.
 
Just read my own post. There are hospital systems that own free-standing facilities, but they are still owned and operated by the hospital, in other words, provider-based.
 
sjstark said:
I have a question regarding place of service (POS) usage. We have a Podiatry facility we will bill for in NY. The facility will bill the facility claims for Medicare, Medicaid, and Medicaid Managed Care plans using a POS 22 (outpatient). We will bill for the professional claims using POS 22 as well. These claims are for E/M and procedural services. The question comes in when billing for commercial insurance plans which will only be billed under the professional claim. If we bill with a POS 22 for these insurance plans we will receive a reduced reimbursement if compared to the same services paid in an office setting. In turn, the facility will lose out on reimbursement because the facility will not bill for a portion of these claims.

It was suggested that we bill using a POS 11 (office) for all the commercial claims and use POS 22 for Medicaid, Medicare, and Medicaid Managed Care. Billing in this manner would get the commercial claims reimbursed the maximum allowed and the governmental claims for the correct professional portion only. Would it be appropriate to bill different place of service codes based on insurance plan? Any input would be greatly appreciated.

Thanks, Scott
Click to expand...

I am uncetain on something here, you state that the facility is billing with POS 22 and the physician is using POS 22. The problem I am having with understanding this situation is that facilities do not bill with POS codes. They use a UB04 with rev codes and bill type. So my question now is what is the facility bill type and the rev codes being used?
 
renakirk said:
Just read my own post. There are hospital systems that own free-standing facilities, but they are still owned and operated by the hospital, in other words, provider-based.
Click to expand...


Yes, it is owned and operated by a hospital. It looks like it could only be place of service 22. Thanks for all the information!!!!

Scott
 
You're welcome. I would not advise billing your Physicians services using POS 11 when the POS is clearly a 22. The Hospital should be billing as well for the facility services.
 
mitchellde said:
I am uncetain on something here, you state that the facility is billing with POS 22 and the physician is using POS 22. The problem I am having with understanding this situation is that facilities do not bill with POS codes. They use a UB04 with rev codes and bill type. So my question now is what is the facility bill type and the rev codes being used?
Click to expand...

You are 100% correct. Unfortunely I am not privy to that information, which is why I phrased it in this manner. Thank you for your response.
 
Well I agree with others then that if it is an outpatient facility to Medicare then it is an outpatient facility to all other carriers. Outpatient or physician office is really based on how your tax structure is set up. This is either or it cannot be both or sometimes one and then the other.
 
And since POS22 is paid a "facility" fee, it would be conisidered "facility" per CPT terms for chemo/hydration/therapeutic infusions, all of which share the CPT statement "these codes are not to be reported by the physician in the facility setting". Is that correct? I think we have a confused clinic (hospital owned), who bills POS 22, but thinks they can bill these codes, since they are not being "split billed" (from the hospital). It's my understanding that the hospital should be reporting those on their side, right?

Thanks
 
Your physician office needs to be owned by the hospital in NY for you to be able to bill SOS 22 for the physicians otherwise you must bill SOS 11. To do otherwise is fraud.
 
Not to sure if thi is to late to comment on... but i has a similar question... what about diagnostic center "free-standing" not hospital owned. we bill pos 11... ive been looking into it and im stuck... pos 49 came as close to what we are as far as outpatient service... does anyone know who can break it down.

Jesse C.
Medical Coder
jesse.chavez@dielp.com
 
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