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POS for EKG - billing debate paging mitchellde thomas 7331 HELP

heartyoga

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MM7631
Special Considerations for Services Furnished to Registered Inpatients When a physician/practitioner furnishes services to a registered inpatient, payment is made under the PFS at the facility rate. To that end, a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, will, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the inpatient hospital POS code 21 is a minimum requirement for purposes of triggering the facility payment under the PFS when services are provided to a registered inpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered inpatient, the appropriate inpatient POS code may be reported consistent with the code list annotated in this section (instead of POS 21). For example, a physician/practitioner may use POS 31, for a patient in a SNF receiving inpatient skilled nursing care, POS 51, for a patient registered in a Psychiatric Inpatient Facility, and POS 61 for patients registered in a Comprehensive Inpatient Rehabilitation Facility. Special Considerations for Outpatient Hospital Departments When a physician/practitioner furnishes services to an outpatient of a hospital, payment is made under the MPFS at the facility rate. Physicians/practitioners who furnish services to a hospital outpatient, including in a hospital outpatient department (including in a providerbased department of that hospital) or under arrangement to a hospital will, at a minimum, report the outpatient hospital POS code 22 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the outpatient hospital POS code 22 is a minimum requirement for purposes of triggering the facility payment amount under the PFS when services are provided to a registered outpatient. If the physician/practitioner is aware of the exact setting the beneficiary is a registered hospital outpatient, the appropriate outpatient facility POS code may be reported consistent with the code list annotated in this section (instead of POS 22). For example, physicians/practitioners may use POS code 23 for services furnished to a patient registered in the emergency room, POS 24 for patients registered in an ambulatory surgical center, and POS 56 for patient...

How does anyone of our experts understand this?

I have a literal biller who INSIST that ER EKGs subsequently admitted as IP/OP should still be billed as ER because ER is where it the physical location of where the EKG is done. I have sent this to her. She is parsing the words, "when the payment is made under the PFS at the facility rate..." Are independent doctors like us not affiliated with the hospital subjected to different ruling?

We have thousands and thousands of EKGs not billed due to this POS coding debate?

Thanks!
 

thomas7331

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If you read the entire MLN article and take the above in context, it is clear that this clarification was issued to ensure that physicians do not bill an office POS (thereby triggering a non-facility payment rate and causing an overpayment) for services rendered to patients in facility. It does not say what this biller is saying - in fact, it suggests that the POS 21 and 22 codes are a 'minimum' requirement, and that the physician may use POS 23 in the ER if they 'aware of the exact setting' - it does not say they must use POS 23. As long as you are billing a facility POS (21, 22, 23, 24, etc. - see list on page 3/4 of the article), you will not be triggering a non-facility payment rate, which is the important thing, and that is the main message of this publication.

I'd also add that for an EKG, there is no global/TC/PC split to the codes - if you are billing the interpretation only, 93010, the facility and non-facility payment rate is exactly the same, so in this particular case there would be no overpayment even if you happened to bill the incorrect office POS 11. So why is your office holding up these claims?? Does your practice not have a manager or compliance officer, or someone in a position of authority for you to take these issues to? How could a debate between a biller hold up thousands of claims? Someone in a position to make a decision in your practice needs to make one here and have your staff get back to their work!
 
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