CLINICAL EXAMPLE - CPT

PHYSICAL EXAMINATION:

VITAL SIGNS:  Afebrile, vital signs stable.

GENERAL:  The patient is a well-developed, well-nourished, female in no acute distress.

ABDOMEN:  Soft.  Uterine contractions are present about every 4-6 minutes.  Fetal heart tones show moderate variability, 15 x 15 accelerations and no decelerations with a baseline of 145 Testing was based over 45 minutes on the fetal monitor. .

PELVIC:  Cervix is very posterior, -2 station, 50% and tight 2 cm, unchanged after walking for an hour.

ASSESSMENT: False labor in a multiparous patient at 36-4/7 weeks' gestation. Fetal status reassuring

PLAN:  Patient was given labor instructions.  She will be calling Dr. Hero's office later in the day to get a refill on her Norco and Fioricet.  She does not want anything else from us now.

Last but not least -  If it wasn’t documented, it wasn’t done! Clear and concise documentation works well.  You don’t have to dictate volumes and pages to support your coding and billing.

The Complexities of Place of Service (POS) Codes – Getting it correct up front!

Welcome back to my blog...  The post for today revolves around Place of Service (POS)  Codes.  POS codes are one of the "first" things to check when claims are being denied.  Below I've outlined what POS codes are, and how their usage can define success or failure when billing physician based, outpatient and inpatient claims.

The Complexities of Place of Service (POS) Codes – Getting it correct up front! 

Physicians and providers practice in many different areas within a hospital setting.  The trick to accurate physician and provider coding/reimbursement requires knowledge and understanding of the Place of Service Codes also known as POS codes. Coders should be diligent in determining the correct POS code up front.  

The place of service will be the determining factor for physician/care provider E&M services to be coded or billed.  The POS is also a factor for facility codes to be coded and billed.  In some circumstances, the hospital and the provider may submit conflicting information if the claim is not coded with the correct POS up fron.  

The ramification of an incorrectly coded claim is the possibility of an inappropriate or incorrect reimbursement to the provider or facility. In reviewing documentation prior to coding, the coder should consider:

a) The correct “place of service” where the evaluation of the patient took place,(such as in the Labor and Delivery, Radiology, or the Emergency room)

b) The hospital/facility licensure of the area within the facility that services were rendered (i.e. an area such as an outpatient office –type that provides physician/provider based services within a hospital setting.)

c) the type of service provided by the physician or care provider. (i.e. evaluation/management, surgery, critical care, infusion, rehabilitation)

The Centers for Medicare/Medicaid services (also known as CMS) and the American Medical Association (also known as the AMA) have developed a specific set of POS codes dedicated to the designation of where medical services have been provided for a patient.  

These codes are standardized and have specific licensure for facilities associated with them.  These codes are known as “Place of Service Codes”.  The most common areas where a physician or care provider may be providing services are:

§  Inpatient Hospital Care Area

o Place of service code = 21

§ Definition:  A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

§  Emergency Department Care Area

o Place of service code = 23

§ Definition:  A portion of a hospital where emergency diagnosis and Hospital treatment of illness or injury is provided

§  Outpatient Hospital Care Area ( or Observation – short stay)

o  Place of Service code = 22

§ Definition:  A portion of a hospital which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

§ Provider Office (to include provider based services that occur within a hospital setting)

o Place of service code = 11 

§ Definition:  Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

§ Urgent Care facility

o Place of service code = 20

§ Definition:  A location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

Each of the areas denoted above, are designated a specific “Place of Service” code by CMS and the American Medical Association. This complete listing can be found in the CPT4 manual.  

The hospital or facility also must have specific state and federal licensure established within these areas for physicians and care providers to render treatment.  Although these areas are all under the same “roof” of the hospital/facility, these service areas are considered “separately identifiable” and the billing of the provider’s services must correspond and be reported correctly when billing the medical claim.

Below are examples of different case scenarios that commonly occur in an OB/GYN hospitalists’ job scope and function.  The brief case examples below give a glimpse of how the importance of the POS code and its relationship to documentation and reimbursement.

Case Scenario #1:  Patti is a 23 week gravida 1 para 0 presenting to L&D with diarrhea and malaise. Patient is evaluated over the course of 30 minutes and discharged back to home with a diagnosis of viral gastroenteritis in addition to the pregnancy.  

This service would be coded with a “place of service” code of 22 -  Outpatient hospital services – Evaluation and management codes 99201-99215

Case Scenario #2 Patti is a 23 week gravida 1 para 0 presenting to L&D with diarrhea and malaise. Patient is evaluated over the course of 7 hours and 30 minutes.  During the course of care, patient received IV hydration and discharged back to home with a diagnosis of viral gastroenteritis in addition to the pregnancy.  

The facility and the physician determined the patient needed full observation status services and was admitted to L&D as observation care.  This service would be coded with a “place of service” code of 22 -  Outpatient hospital services,  E&M services for the physician/provider would be In/out same day hospital service codes of 99234 – 99236.  

The Facility would be able to bill for the room, and any associated ancillary services such as the IV hydration and any medications that were included in the hydration.

Case Scenario #3:  Patti is a 23 week gravida 1 para 0, presenting to L&D with decreased fetal movement and abnormal bleeding from the vaginal area.  Patient is evaluated over the course of 60 minutes, and determined that the patient has a possible placental abruption.  

The orders are then sent that the patient will be “admitted” as an inpatient.  Dr. Stamps then documents an H&P/admission and a bed is secured for the patient in the inpatient area of L&D.  This service would be coded with a “place of service” code of 21.  The E&M services billable by Dr. Stamps would be the Inpatient Admission codes of 99221 – 99223.

Case Scenario #4:  Dr. Stamps is called to the Emergency room to see patient Patti, a 23 week gravida 1 para 0, who was a passenger in a motor vehicle accident and currently being evaluated by the Emergency department for neck pain.  Dr. Stamps was called down to the ED to evaluate the patient, as she is 23 weeks pregnant.  

Dr. Stamps does a full evaluation of the patient in the ED area and denotes that Patti has a mild abdominal contusion from the seat belt restraint, but no other major concerning “pregnancy related” issues.  This service would be coded with a “place of service” code of 23. The E&M services billable by Dr. Stamps would be the Emergency Department codes of 99281 – 99285

In 2012, CMS and the OIG work plan have targeted place-of-service errors for audit.  In addition, many hospitals and hospital based physician practices are finding POS problems on their own through careful screening and the usage of software connected to scrubbing of claim edits to match the place of service with specific CPT codes.  

Unfortunately, POS errors can cause areas of overpayment, and incorrect reimbursement for the services provided.  The software should also be tested to confirm that the claim edits and scrubs are set up appropriately.

In addition, the 2012 OIG work plan, has targeted three POS codes as potential areas of audit, with the “risk factor” of inappropriate reimbursement to either the physician/provider office, or the facility where the services took place.

· POS code 11 (offices),

· POS code 21 (hospital inpatient departments), and

· POS code 22 (hospital outpatient departments, such as provider-based entities).

Compliance for POS errors is difficult, as the provider may submit codes for physician based services well ahead of the facility.  If the facility has “changed” the POS code and not notified the provider office, the two claims submitted (the provider claim and the facility claim) will not “match”, and thus a red-flag may go up that these claims need to be reviewed by the 3rd party payers or insurance carriers. 

For coders, there seems to be an “under-education” and misunderstanding of POS codes.  Not only do coders not have a good grasp of the importance of POS codes, but physicians and providers also do not understand them.

In the nuts and bolts world of the coder, the POS code(s) should be one of the first areas looked at before determining the E&M billable services, or ancillary services to be coded and billed.  Coders need to be better educated in understanding the importance of the POS codes, and the direct relationship and impact on the reimbursement for providers and the facilities they work in.

For a full listing and definition of place of service codes, and their appropriate usage, the listing and definitions of POS codes found in the current CPT4 manual.  Coders and also find more specific Medicare/Medicaid requirements for correct POS assignment and documentation at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2282CP.pdf and

http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/clm104c26.pdf

ICD-9 to ICD-10 PCS -- Robotic Assisted Procedures - Where do we go from here??

The conversion date for ICD-10CM and PCS has now been confirmed by CMS to be October 1, 2014. The challenge for coders is to continue their education and proficiency in the new ICD-10 pcs system. The onus to become proficient in this new coding code-set system begins in earnest. 

Not only do coders need to understand the new ICD-10 pcs system and its guidelines, but they need a very clear understanding of the devices, anatomy and physiology too.