(Medicare Claims Processing Manual)

There may be use of nursing homes as the hospice patients home, where the patient resides in the facility but is receiving a home level of care. In addition, hospices are also operating houses or hospice residential entities where hospice patients rec eive a home level of care. In these cases, physicians and nonphysician practitioners, including the patients independent attending physician or nurse practitioner, shall use the appropriate POS code representing the particular setting, e.g., POS code 32 f or nursing home, POS code 13 for an assisted living facility, or POS code 14 for group home.   Special Considerations for Non -residential Opioid Treatment Facility (Code  58)  NOTE: OUD treatment services furnished at Opioid Treatment Programs are not considered physician services and are separately paid under the bundled payment established under sections 1833(a)(1)(CC) and 1834(w) of the Social Security Act.   Paper Claims   Adjudicate paper claims with codes from the National POS code set as you would for electronic claims.  10.6 - A/B Medicare Administrative Contractor (MAC) (B) Instructions for Place of Service (POS) Codes  (Rev. 3490, Issued: 04- 01-16, Effective: 04 -25-16, Implementation: 04- 25-16)  For purposes of payment under the Medicare Physician Fee Schedule (MPFS), the POS code is generally used to reflect the actual setting where the beneficiary receives the face-to-face service.  For example, if the physicians face- to-face encounter with a p atient occurs in the office, the correct POS code on the claim, in general, reflects the 2 -digit POS code 11 for office.  In these instances, the 2- digit POS code (Item 24B on the claim Form CMS -1500) will match the address and ZIP entered in the service l ocation (Item 32 on the 1500 Form)  the physical/geographical location of the physician.  However, there are two exceptions to this general rule  these are for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital.  In these cases, the correct POS code -- regardless of where the face -to-face service occurs -- is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a minimum POS code 19 or 22, for outpatient services performed off campus or on campus) as discussed in section 10.5 of this chapter.  So, if in the above example, the patient seen in the physicians office is actually an inpatient of the hospital, POS code 21, for inpatient hospita l, is correct.  In this example, the POS code reflects a different setting than the address and ZIP code of the practice location (the physicians office).   For MPFS payment purposes the determinant of payment is the locality where the physician or supplier furnished the service.  Medicare has both facility and non- facility designations for services paid under the physician fee schedule.  In accordance with Chapter 1, Section 10.1.1 (Payment Jurisdiction Among Local Medicare Administrative Contractors (MACs) for Services Paid Under the Physician Fee Schedule and Anesthesia Services) of this manual, the jurisdiction for processing a request for payment for servi ces paid under the MPFS is governed by the payment locality where the physician or supplier furnished the service and will be based on the ZIP code.  CMS requires that the address and ZIP code of the physicians practice location be placed on the claim for m in order to determine the appropriate locality -- item 32 on the paper claim Form CMS 1500 or in the corresponding loop on its electronic equivalent.   For specific POS instructions and determination of the applicable payment locality for the PC (professional interpretation) and the TC of diagnostic tests see chapter 13, section 150 of this manual.  For general policy on POS code assignment, see chapter 1 2, section 20.4.2 of this manual regarding the site of service payment differential under MPFS.   If the physician bills for lab services performed in his/her office, the POS code for "Office" is shown.  If the physician bills for a lab test furnished by another physician, who maintains a lab in his/her office, the code for "Other" is shown.  If the physician bills for a lab service furnished by an independent lab, the code for "Independent Laboratory" is used.  Items 21 and 22 on the Form CMS -1500 must be completed for all laboratory work performed outside a physician's office.  If an independent lab bills, the place where the sample was taken is shown.  An independent laboratory taking a sample in its laboratory shows "81" as place of service.  If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient (POS code 21), off campus -outpatient hospital (POS code 19), or on campus -outpatient hospital (POS code 22), respectively.   For hospital visits by physicians, presume, in the absence of evidence to the contrary, that visits billed for were made.  However, review a sample of physician's records when there are questionable patterns of utilization.  Confirm these visits where the medical facts do not support the frequency of the physician's visits or in cases of beneficiary complaints.   If questioning whether the visit had been made, ascertain whether the physician's own entry is in the patient's record at the provider.  Accept an entry where the nurses' notes indicate that the physician saw the patient on a given day.  A statement by the beneficiary is also acceptable documentation if it was made close to the alleged date of the visit.  Entries in the physician's records represent possible secondary evidence. However, these are of less value since they are self -serving statements.  Exercise judgment regarding their authenticity.  The policy requiring daily physician visits is not conclusive if, in the individual case, the facts did not support a finding that daily visits were made.  If a claim lacks a valid place of service (POS) code in item 24b, or contains an invalid POS in item 24b, return the claim as unprocessable to the provider or supplier, using Group Code CO, Claim Adjustment Remark Code (CARC) 16, and Remittance Advice Remark Code (RARC) M77.  Effective for claims received on or after April 1, 2004, only one POS may be submitted on the Form CMS -1500 for services paid under the MPFS and anesthesia services.  If the place of service is missing and the MAC cannot infer the place of service from the procedure code billed (e.g., a procedure code for which the definition is not site specific or which can be performed in more than one setting), then return services as unprocessable.   If place of service is inconsistent with procedure code billed, then edit for consistency or compatibility between the place of service and site- specific procedure codes.  If the place of service is valid but inconsistent or incompatible with the procedure  billed (e.g., the place of service is inpatient hospital and the procedure code billed is office visit), then return services as unprocessable since the MAC typically will not know whether the procedure code or the place of service is incorrect in such instances.  If place of service is invalid, then edit for the validity of the place of service coding.  If the place of service code is not valid (e.g., the number designation has not been assigne d or defined by CMS), then return services as unprocessable.   10.7 - Type of Service ( TOS)  (Rev. 2814, Issued: 11- 15-13, Effective: 01 -01-14, Implementation: 01- 06-14)  Medicare Administrative Contractors (MACs) must assign the proper TOS using the annual HCPCS update from the CMS mainframe.  Changes to this list are issued annually via a Recurring Update Notification.  Some procedures may have more than one applicable TO S.  For claims received on or after April 3, 1995, CWF produced alerts on codes with incorrect TOS designations.  Effective July 3, 1995, CWF began rejecting codes with incorrect TOS designations.  The only exceptions to this annual update are:    Surgical services billed for dates of service through December 31, 2007, containing the ASC facility service modifier SG must be reported as TOS F.  Effective for services on or after January 1, 2008, the SG modifier is no longer applicable for Medicare services.  ASC providers should discontinue applying the SG modifier on ASC facility claims.  The indicator F does not appear in the TOS table because its use depends upon claims submitted with POS 24 (ASC Facility) from an ASC (specialty 49).  This became  effective for dates of service January 1, 2008 and after.   Surgical services billed with an assistant- at-surgery modifier (80- 82, AS) must be reported with TOS 8.  The 8 indicator does not appear on the TOS table because its use is dependent upon the use of the appropriate modifier.  (See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 12, "Physician/Nonphysician Practitioner," for instructions on when assistant -at-surgery is allowable.)    TOS H appears in the list of descriptors.  However, it does not appear in the table.  In CWF, "H" is used only as an indicator for hospice.  The contractor should not submit TOS H to CWF at this time.    For outpatient services, when a transfusion medicine code appears on a claim that also contains a blood product, the service is paid under reasonable charge at 80%, coinsurance and deductible apply.  When transfusion medicine codes are paid under the clini cal laboratory fee schedule pay at 100%, coinsurance and deductible do not apply.   NOTE:  For injection codes with more than one possible TOS designation, use the following guidelines when assigning the TOS:   When the choice is L or 1,   Use TOS L when the drug is used related to ESRD; or    Use TOS 1 when the drug is not related to ESRD and is administered in the office.   When the choice is G or 1:    Use TOS G when the drug is an immunosuppressive drug; or    Use TOS 1 when the drug is used for other than immunosuppression.  When the choice is P or 1,   Use TOS P if the drug is administered through durable medical equipment (DME); or    Use TOS 1 if the drug is administered in the office.  The place of service or diagnosis may be considered when determining the appropriate TOS.  The descriptors for each of the TOS codes listed in the annual HCPCS update are:   Type of Service Indicators   Code  Description  0 Whole Blood  1 Medical Care  2 Surgery  3 Consultation  4 Diagnostic Radiology  5 Diagnostic Laboratory  6 Therapeutic Radiology  7 Anesthesia  8 Assistant at Surgery  9 Other Medical Items or Services  A Used DME  B High Risk Screening Mammography  C Low Risk Screening Mammography  D Ambulance  E Enteral/Parenteral Nutrients/Supplies  F Ambulatory Surgical Center (Facility Usage for Surgical Services)  G Immunosuppressive Drugs  H Hospice  J Diabetic Shoes  K Hearing Items and Services  L ESRD Supplies  Code  Description  M Monthly Capitation Payment for Dialysis  N Kidney Donor  P Lump Sum Purchase of DME, Prosthetics, Orthotics  Q Vision Items or Services  R Rental of DME  S Surgical Dressings or Other Medical Supplies  T Outpatient Mental Health Treatment Limitation  U Occupational Therapy  V Pneumococcal/Flu Vaccine  W Physical Therapy   10.8 - Requirements for Specialty Codes  (Rev. 1725, Issued: 05- 01-09, Effective: 07 -01-09, Implementation: 07- 06-09)  Medicare physician/non- physician practitioner specialty codes describe the specific/unique types of medicine that physicians and non- physician practitioners (and certain other suppliers) practice.  Physicians self -designate their Medicare physician specialty on their Medicare enrollment application (CMS -855I) or on the Internet -based Provider Enrollment, Chain and Ownership System.  Non -physician practitioners are assigned a Medicare specialty code when they enroll based on their profession.  Specialty code s are used by CMS for programmatic and claims processing purposes.   A. A physician specialty association will submit a specialty code request to the Director, Division of Practitioner Services, Center for Medicare Management, Centers for Medicare & Medicaid Services, Mail Stop C4 -01-26, 7500 Security Blvd., Baltimore, MD 2 1244.  Medicare contractors shall not add any specialty codes to the list.  They must send all requests for expansion of the specialty code list to the Director, Division of Practitioner Services, at the address above.   B. When considering a request for expanding the specialty code list for physician and non-physician practitioners, CMS will take into consideration the following:    Whether the requested specialty has the authority to bill Medicare independently;    The requesters stated reason or purpose for the code;    Evidence that the practice pattern of the specialty is markedly different from that of the dominant parent specialty;    Evidence of any specialized training and/or certification required;    Whether the specialty treats a significant volume of the Medicare population;