POS 11 or 81

hsmith67

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Any assistance to help with a debate is greatly appreciated. Some of the questions may seem ridiculous, but I'm trying to resolve a debate.

Scenario:
20+ locations of a primary/urgent care business crossing state lines. High complexity CLIA certificate at a location in state "X" where high complexity labs are run. This location is not solely a "lab", patients are seen at this physical address as well with professional claims submitted for this location. Locations from state "X" and state "Y" collect specimens and forward to the location where the lab equipment is and the tests are run. For billing purposes, what should go in the following fields of a HCFA:

Box 17 Referring provider: Provider requesting the lab to be done that saw the patient and where specimen was collected or someone else?

Box 24 B Place of Service: 11 or 81? (remember, this address also submits professional claims with POS 11)

Box 24 J: MD at the location where test is run with High Complexity CLIA or someone else (e.g., clinical lab director)

Box 32 Service Facility: Facility where test was performed/attached to High Complexity CLIA or something else?

A concern that has been brought up is that if we use POS 11 for the claims submitted for the lab the payers will kick it back/deny as the patient was seen the same day in another state for an office visit/E&M and that is not possible for the patient to be seen in two states on the same date of service (using date of collection as DOS for the lab).

Thanks,
Hunter Smith, CPC
 

Pam Brooks

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Box 17 Referring provider: Provider requesting the lab to be done that saw the patient and where specimen was collected or someone else? Our payers in NH want to see the PCP in this box, regardless. Otherwise, I'd indicate the ordering physician.

Box 24 B Place of Service: 11 or 81? (remember, this address also submits professional claims with POS 11) If it's a lab within a practice, under the direction/management/ownership of the practice or practice entity, then it's POS 11. If it's a separate company/free standing lab, or the entity has designated that particular space in the office as an outpatient department of the hospital, then you'd code otherwise. POS 81 seems pretty unlikely, unless Lab Company A is renting space from Practice B. The fact that you're submitting a 1500 for this claim, tells me that this is not a department of the hospital, either.

Box 24 J: MD at the location where test is run with High Complexity CLIA or someone else (e.g., clinical lab director) Supervising provider at lab practice site.

Box 32 Service Facility: Facility where test was performed/attached to High Complexity CLIA or something else? The name of the practice or the practice entity, if it's a practice or corporate-owned lab. Otherwise the name of the independent lab.

A concern that has been brought up is that if we use POS 11 for the claims submitted for the lab the payers will kick it back/deny as the patient was seen the same day in another state for an office visit/E&M and that is not possible for the patient to be seen in two states on the same date of service (using date of collection as DOS for the lab). What? we are in ME and NH and never have this issue. I don't buy it. Labs shouldn't bundle against OVs. And I could conceivably have an office visit here in NH at 8 a.m., hop a plane, and have lab work done at 3 p.m. in Los Angeles. Nope, the denials must be for another reason.

Have a good day.
 

hsmith67

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Pam,

Thanks so much for your reply.

For box 24J you say "Supervising provider at lab practice site." Do you mean the provider that does professional services at the same site as the lab equipment? If so, he is in one state (SC) while the specimen was obtained in another state (NC) and he is not involved with supervision of the lab equipment, it's just a coincidence that he renders professional services at the same address as the lab equipment. If we bill BCBS NC they kick the claim back as "provider not credentialed, out of network" since he is credentialed with BCBS of SC. Or, should I list a clinical lab director NPI in 24J if they are credentialed with BCBS of NC and BCBS of SC? Or, do I ask BCBS of NC to credential him and consider him "in network" with BCBS of NC even though he is in SC since the office is just 5 miles from the NC/SC state line?

Are we to bill the E&M with the rendering provider in NC to BCBS of NC and then bill the lab service with the physician in SC to BCBS of SC?

Thanks again so much for your input!

Hunter Smith, CPC
 
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