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Radiology claim form billing

amyfust

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Looking for help from someone familiar with Radiology 1500 claim form billing. My radiologists read all of the outreach x-rays from a lot of rural hospitals and for the local clinics and hospitals from their location in the hospital in our town. There is some confusion as to how box 24B should be filled out. Some think that since our radiologists are located in the hospital all claims should be billed as 22 Out PT even if they are ER, INPT or Clinic visits. My thoughts are that box 24B should be marked depending on the status of the patient which could vary from 11, 21, 22 or 23 and that box 32 is what should take care of billing for the location where the radiologists read the x-rays. Any help welcomed.
 

CodingKing

True Blue
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3,955
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Place of service is generally where the patient received the face to face portion.

Heres some information from a Medicare MLN article

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/Downloads/MM7631.pdf

Also from the transmittal from Medicare:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2679CP.pdf

This instruction establishes that for all services – with two (2) exceptions -- paid under the MPFS that the POS
code to be used by the physician and other supplier shall be assigned as the same setting in which the
beneficiary received the face-to-face service. Because a face-to-face encounter with a physician/practitioner is
required for nearly all services paid under the MPFS and anesthesia services, this rule will apply to the
overwhelming majority of PFS services. In cases where the face-to-face requirement is obviated such as those
when a physician/practitioner provides the professional component (PC)/interpretation of a diagnostic test, from
a distant site, the POS code assigned by the physician /practitioner shall be the setting in which the beneficiary
received the technical component (TC) service.
For example: A beneficiary receives an MRI at an outpatient
hospital near his/her home. The hospital submits a claim that would correspond to the TC portion of the MRI.
The physician furnishes the PC portion of the beneficiary’s MRI from his/her office location – POS code 22
shall be used on the physician’s claim for the PC to indicate that the beneficiary received the face-to-face
portion of the MRI, the TC, at the outpatient hospital.

There are two (2) exceptions to this face-to-face provision/rule in which the physician always uses the POS
code where the beneficiary is receiving care as a registered inpatient or an outpatient of a hospital, regardless of
where the beneficiary encounters the face-to-face service.
The correct POS code assignment shall be for that
setting in which the beneficiary is receiving inpatient care or outpatient care from a hospital including the
inpatient hospital (POS code 21) or the outpatient hospital (POS code 22) In other words, reporting the
inpatient hospital POS code 21 or the outpatient hospital POS code 22, is a minimum requirement for purposes
of triggering the facility payment under the PFS when services are provided to a registered inpatient or an
outpatient of a hospital respectively. If the physician/practitioner is aware of the exact setting the beneficiary is
a registered inpatient (or hospital outpatient), the appropriate inpatient POS code (or appropriate outpatient POS
code) may be reported consistent with the code list annotated in Pub. 100-04, Medicare Claims Processing
Manual, chapter 26, section 10.5. However, it is more important that the physician/practitioner report the POS
consistent with the patient’s general inpatient or outpatient hospital status than the precise inpatient/ outpatient
POS code (in order to trigger the facility payment rate under the PFS). Pub. 100-04, Medicare Claims
Processing Manual, chapter 26, already requires this for physician services (and for certain independent
laboratory services) provided to beneficiaries in the inpatient hospital and this CR clarifies this exception and
extends it to beneficiaries of the outpatient hospital, as well.
 
Last edited:

chembree

Guru
Messages
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Location
Dallas, GA
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I agree that the POS code is generally where the patient received the face to face portion.

I think you are right and they may be thinking of box 32 and that is based off where the physician provides the service for the exam:

When the physician’s interpretation of a diagnostic test is billed separately from the technical component, as identified by modifier -26, the interpreting physician (or his or her billing agent) must report the address and ZIP code of the interpreting physician’s location on the claim form. If the professional interpretation was furnished at an unusual and infrequent location for example, a hotel, the locality of the professional interpretation is determined based on the Medicare enrolled location where the interpreting physician most commonly practices. The address and ZIP code of this practice location is entered in Item 32 on the paper claim Form CMS 1500 (or its electronic equivalent).


https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2679CP.pdf
 
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