- Email: [email protected]
New Place-of-Service Rules
REIMBURSEMENT ROUNDS
EZEQUIEL SILVA III, MD
New Place-of-Service Rules INTRODUCTION
CMS recently issued clarifying instructions for reporting the location where the professional component (PC) of radiologic services are provided [1]. These place-of-service (POS) rules took effect April 1, 2013, and could affect the billing operations of radiology practices. In this column, I describe the new instructions and the effects on two important billing-related topics: (1) global billing and (2) remote interpretations. BACKGROUND
Billing claims are submitted to Medicare using the CMS-1500 form (or its electronic equivalent). The CMS1500 form requires two different pieces of information related to the location of a radiologic service. First, a POS code from the standard set of CMS POS codes is required on line 24b of the CMS-1500 form; this code identifies the setting where a patient received a face-to-face encounter. In radiology, the face-to-face requirement is often obviated by the fact that the interpretation may occur at a distant site. Identifying the proper setting is important because Medicare makes different payments for certain services across different POS settings. For example, payment for a service provided in a hospital may be lower than payment for the same service provided in an office, where the physician incurs greater overhead. In fact, the recent CMS POS transmittal is partly a response to findings by the Office of Inspector General of the U.S. Department of Health and Human Services that physicians frequently report improper POS codes, leading to inappropriately higher payments [2]. Second, a physical address, including ZIP code, is required and entered on line 32 of the CMS-1500 form (“Service Facility Location Information”). The physical address of the service is important because address determines the “payment locality,” and payments are different across different
payment localities. For example, payment for a service in Manhattan would be higher than payment for the same service in rural South Dakota because Manhattan has a higher geographic practice cost index. Radiologic services have two important differences from most other physician services: (1) our services include a distinct technical component (TC) and a distinct professional component (PC), which when combined constitute the global payment, and (2) the PC services are often provided at different sites from those where the images were acquired (the TC). RULES FOR PLACE-OFSERVICE AND ADDRESS ASSIGNMENT
For interpretation services, the POS code should reflect the site where the TC was provided. This is the case whether the PC occurs at the same site as the TC or at a distant site. For example, if a patient undergoes MR as an outpatient at a hospital, but the radiologist interprets the examination in his or her office, the POS code should indicate “outpatient hospital” (POS 22). The address and ZIP code should indicate the location where the PC was provided. Occasionally, the PC may be furnished at an unusual and infrequent location, such as a hotel. In this case, the address and, hence, the payment locality for the PC should be the Medicare-enrolled location where the interpreting physician most commonly practices. IMPLICATIONS FOR GLOBAL BILLING
Global billing involves submitting a single claim for both the TC and PC of a radiologic service. CMS has instructed that billing globally requires that the TC and PC be furnished (1) by the same physician or supplier entity and (2) within the same payment locality. It seems the “same physician or supplier entity” requirement is sat-
© 2013 American College of Radiology 0091-2182/13/$36.00 ● http://dx.doi.org/10.1016/j.jacr.2013.01.030
isfied if the PC is provided by a radiologist employed by the group. It is not clear, however, if this requirement is satisfied when the radiologist is an independent contractor reassigning billing rights to the group [3]. If these criteria for global billing are not met, for example when the TC and PC are provided by different physicians or if the PC is provided in a different payment locality, global billing is prohibited. When global billing is prohibited, the PC and TC must be separately billed. For the PC claim, the address and ZIP code of the interpreting physician’s location would be provided. For the TC claim, the POS code and physical address would be the site at which the image was acquired. IMPLICATIONS FOR REMOTE INTERPRETATIONS
Remote interpretations, such as with teleradiology, frequently involve different payment localities for the TC versus the PC. As such, global billing is not an option. The POS code for the PC claim is still the place where the beneficiary received the TC. However, the physical address on the claim form should be the site where the interpretation was provided. Importantly, the radiologists must be enrolled and submit the claim to the Medicare administrative contractor (MAC) with jurisdiction over the locality where the PC was provided [3]. It should be noted that Medicare does not pay for services performed outside the United States. When the PC is submitted to a different MAC the radiologist and the radiology group must be sure to enroll with the MAC with jurisdiction over the location where the radiologist provided the interpretation. This may mean that the radiology group must enroll in multiple MAC jurisdictions if the group’s employed or contracted radiologists read from different states locations. In some cases MACs have been reluctant or unwilling to accept the 325
326 Reimbursement Rounds
home office of the employed physician as the practice location of the group. Nevertheless, there may be no other viable address for the group to list as its practice location within the MAC’s jurisdiction if the group’s only contact with the state is the radiologist providing remote interpretations. INDEPENDENT DIAGNOSTIC TESTING FACILITIES AND SELF-REFERRAL
It would seem rare that an independent diagnostic testing facility could bill globally under these new instructions because global billing in this setting would require the same physician to supervise the study and interpret the study, both within the same payment locality. Likewise, self-referred studies performed in the referring physician’s office seem ineligible for global billing because different physicians are providing the TC and PC, and the PC is likely provided by a nonemployee, probably at a remote site. Furthermore, the rules regarding antimarkup payment limitations may apply and prohibit global billing in the first place [4]. TECHNOLOGY IMPLICATIONS
It is important that billing entities have the ability to identify exactly where the interpretation was provided so that the proper POS code and physical address can be provided. Location information enables billing entities to determine if global billing is appropriate or not. If not, location information is necessary to determine the MAC to which the respective TC and PC claims would be submitted. REAL-LIFE EXAMPLES Example 1
A practice has multiple office locations where both TC and PC services are provided. A patient undergoes MR of the knee at site A. The radiologist at site A is a body radiologist who does not
interpret musculoskeletal (MSK) MR studies. As such, an MSK radiologist at site B, who is an employee of the practice, “pulls the study” from the practice’s PACS and provides the interpretation. If site A and site B are within the same Medicare payment locality, a global bill would be permitted, and the POS code and address on the claim form should indicate site A. It is not clear from CMS’s guidance if global billing is allowed if the MSK radiologist is an independent contractor reassigning billing rights to the group. If, however, site A and site B are in different Medicare payment localities (ie, across state lines), global billing is not allowed. A separate TC claim should be made from site A on the basis of site A’s POS code and physical address and submitted to the MAC with jurisdiction over this location. A separate PC claim should be filed, and the POS code and address for the PC claim should be based on the location where the interpretation was provided. Example 2
A radiology group contracts with a teleradiology company to provide subspecialty interpretations of MSK MR studies. A patient undergoes knee MR as an outpatient at hospital A. The study is sent remotely to the teleradiology company, which provides the PC. The hospital should file its own TC claim. The teleradiology company would submit a separate PC claim and indicate the outpatient hospital POS code and indicate the physical address where the interpretation was provided. This is true even if the teleradiology company has reassigned its billing rights to the group. The PC claim would be filed with the MAC with jurisdiction over the address where the interpretation was provided. CONCLUSIONS
The recent guidance from CMS regarding POS issues has significant billing implications for radiology practices.
I caution that radiologists should seek guidance from the appropriate MAC when POS-related questions arise. Importantly it is no longer appropriate to simply bill all claims as global without carefully considering the site at which the PC was provided. In general, the POS code reflects the site of the TC regardless of where the PC is provided. However, when the TC and PC take place in different payment localities, separate TC and PC claims are required, and CMS requires the physical location of the interpretation to be indicated on the PC claim. Furthermore, later determining the location where the interpretation was provided may be a challenge for billing entities because radiology IT systems may not include the interpretation location in the information shared with the billing entity. ACKNOWLEDGMENT I acknowledge Tom Greeson, Esq, and Paul Pitts, Esq, for their review of this column. REFERENCES 1. Centers for Medicare and Medicaid Services. Pub 100-04 Medicare claims processing: transmittal 2613, change request 7631. Available at: http://www.cms.gov/Regulations-and-Guidance/ Guidance/Transmittals/downloads/R2613CP. pdf. Accessed March 12, 2013. 2. Pilcher LS. Review of place-of-service coding for physician services processed by Medicare Part B contractors during calendar year 2009 (A-01-10-00516). Available at: https://oig. hhs.gov/oas/reports/region10/11000516.pdf. Accessed January 27, 2013. 3. Greeson TW, Pitts PW. CMS place-of-service instructions continue to confound providers. imagingBiz. Available at: http://www. imagingbiz.com/articles/view/cms-place-ofservice-instructions-continue-to-confoundproviders. Accessed January 27, 2013. 4. American College of Radiology. ACRRBMA joint guidance on CMS’ place of service (POS) coding instructions. Available at: http://www.acr.org/Advocacy/EconomicsHealth-Policy/Billing-Coding/Coding-Source/ Articles/2012-Nov-Dec/Coding-Source-NovDec-2012/POS-Coding-Instruction. Accessed January 27, 2013.
Ezequiel Silva III, MD, South Texas Radiology Group, 8401 Datapoint, Suite 600, San Antonio, TX 78229; University of Texas Health Science Center at San Antonio, Department of Radiology, MC 7800, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900; e-mail: [email protected].
EZEQUIEL SILVA III, MD
New Place-of-Service Rules INTRODUCTION
CMS recently issued clarifying instructions for reporting the location where the professional component (PC) of radiologic services are provided [1]. These place-of-service (POS) rules took effect April 1, 2013, and could affect the billing operations of radiology practices. In this column, I describe the new instructions and the effects on two important billing-related topics: (1) global billing and (2) remote interpretations. BACKGROUND
Billing claims are submitted to Medicare using the CMS-1500 form (or its electronic equivalent). The CMS1500 form requires two different pieces of information related to the location of a radiologic service. First, a POS code from the standard set of CMS POS codes is required on line 24b of the CMS-1500 form; this code identifies the setting where a patient received a face-to-face encounter. In radiology, the face-to-face requirement is often obviated by the fact that the interpretation may occur at a distant site. Identifying the proper setting is important because Medicare makes different payments for certain services across different POS settings. For example, payment for a service provided in a hospital may be lower than payment for the same service provided in an office, where the physician incurs greater overhead. In fact, the recent CMS POS transmittal is partly a response to findings by the Office of Inspector General of the U.S. Department of Health and Human Services that physicians frequently report improper POS codes, leading to inappropriately higher payments [2]. Second, a physical address, including ZIP code, is required and entered on line 32 of the CMS-1500 form (“Service Facility Location Information”). The physical address of the service is important because address determines the “payment locality,” and payments are different across different
payment localities. For example, payment for a service in Manhattan would be higher than payment for the same service in rural South Dakota because Manhattan has a higher geographic practice cost index. Radiologic services have two important differences from most other physician services: (1) our services include a distinct technical component (TC) and a distinct professional component (PC), which when combined constitute the global payment, and (2) the PC services are often provided at different sites from those where the images were acquired (the TC). RULES FOR PLACE-OFSERVICE AND ADDRESS ASSIGNMENT
For interpretation services, the POS code should reflect the site where the TC was provided. This is the case whether the PC occurs at the same site as the TC or at a distant site. For example, if a patient undergoes MR as an outpatient at a hospital, but the radiologist interprets the examination in his or her office, the POS code should indicate “outpatient hospital” (POS 22). The address and ZIP code should indicate the location where the PC was provided. Occasionally, the PC may be furnished at an unusual and infrequent location, such as a hotel. In this case, the address and, hence, the payment locality for the PC should be the Medicare-enrolled location where the interpreting physician most commonly practices. IMPLICATIONS FOR GLOBAL BILLING
Global billing involves submitting a single claim for both the TC and PC of a radiologic service. CMS has instructed that billing globally requires that the TC and PC be furnished (1) by the same physician or supplier entity and (2) within the same payment locality. It seems the “same physician or supplier entity” requirement is sat-
© 2013 American College of Radiology 0091-2182/13/$36.00 ● http://dx.doi.org/10.1016/j.jacr.2013.01.030
isfied if the PC is provided by a radiologist employed by the group. It is not clear, however, if this requirement is satisfied when the radiologist is an independent contractor reassigning billing rights to the group [3]. If these criteria for global billing are not met, for example when the TC and PC are provided by different physicians or if the PC is provided in a different payment locality, global billing is prohibited. When global billing is prohibited, the PC and TC must be separately billed. For the PC claim, the address and ZIP code of the interpreting physician’s location would be provided. For the TC claim, the POS code and physical address would be the site at which the image was acquired. IMPLICATIONS FOR REMOTE INTERPRETATIONS
Remote interpretations, such as with teleradiology, frequently involve different payment localities for the TC versus the PC. As such, global billing is not an option. The POS code for the PC claim is still the place where the beneficiary received the TC. However, the physical address on the claim form should be the site where the interpretation was provided. Importantly, the radiologists must be enrolled and submit the claim to the Medicare administrative contractor (MAC) with jurisdiction over the locality where the PC was provided [3]. It should be noted that Medicare does not pay for services performed outside the United States. When the PC is submitted to a different MAC the radiologist and the radiology group must be sure to enroll with the MAC with jurisdiction over the location where the radiologist provided the interpretation. This may mean that the radiology group must enroll in multiple MAC jurisdictions if the group’s employed or contracted radiologists read from different states locations. In some cases MACs have been reluctant or unwilling to accept the 325
326 Reimbursement Rounds
home office of the employed physician as the practice location of the group. Nevertheless, there may be no other viable address for the group to list as its practice location within the MAC’s jurisdiction if the group’s only contact with the state is the radiologist providing remote interpretations. INDEPENDENT DIAGNOSTIC TESTING FACILITIES AND SELF-REFERRAL
It would seem rare that an independent diagnostic testing facility could bill globally under these new instructions because global billing in this setting would require the same physician to supervise the study and interpret the study, both within the same payment locality. Likewise, self-referred studies performed in the referring physician’s office seem ineligible for global billing because different physicians are providing the TC and PC, and the PC is likely provided by a nonemployee, probably at a remote site. Furthermore, the rules regarding antimarkup payment limitations may apply and prohibit global billing in the first place [4]. TECHNOLOGY IMPLICATIONS
It is important that billing entities have the ability to identify exactly where the interpretation was provided so that the proper POS code and physical address can be provided. Location information enables billing entities to determine if global billing is appropriate or not. If not, location information is necessary to determine the MAC to which the respective TC and PC claims would be submitted. REAL-LIFE EXAMPLES Example 1
A practice has multiple office locations where both TC and PC services are provided. A patient undergoes MR of the knee at site A. The radiologist at site A is a body radiologist who does not
interpret musculoskeletal (MSK) MR studies. As such, an MSK radiologist at site B, who is an employee of the practice, “pulls the study” from the practice’s PACS and provides the interpretation. If site A and site B are within the same Medicare payment locality, a global bill would be permitted, and the POS code and address on the claim form should indicate site A. It is not clear from CMS’s guidance if global billing is allowed if the MSK radiologist is an independent contractor reassigning billing rights to the group. If, however, site A and site B are in different Medicare payment localities (ie, across state lines), global billing is not allowed. A separate TC claim should be made from site A on the basis of site A’s POS code and physical address and submitted to the MAC with jurisdiction over this location. A separate PC claim should be filed, and the POS code and address for the PC claim should be based on the location where the interpretation was provided. Example 2
A radiology group contracts with a teleradiology company to provide subspecialty interpretations of MSK MR studies. A patient undergoes knee MR as an outpatient at hospital A. The study is sent remotely to the teleradiology company, which provides the PC. The hospital should file its own TC claim. The teleradiology company would submit a separate PC claim and indicate the outpatient hospital POS code and indicate the physical address where the interpretation was provided. This is true even if the teleradiology company has reassigned its billing rights to the group. The PC claim would be filed with the MAC with jurisdiction over the address where the interpretation was provided. CONCLUSIONS
The recent guidance from CMS regarding POS issues has significant billing implications for radiology practices.
I caution that radiologists should seek guidance from the appropriate MAC when POS-related questions arise. Importantly it is no longer appropriate to simply bill all claims as global without carefully considering the site at which the PC was provided. In general, the POS code reflects the site of the TC regardless of where the PC is provided. However, when the TC and PC take place in different payment localities, separate TC and PC claims are required, and CMS requires the physical location of the interpretation to be indicated on the PC claim. Furthermore, later determining the location where the interpretation was provided may be a challenge for billing entities because radiology IT systems may not include the interpretation location in the information shared with the billing entity. ACKNOWLEDGMENT I acknowledge Tom Greeson, Esq, and Paul Pitts, Esq, for their review of this column. REFERENCES 1. Centers for Medicare and Medicaid Services. Pub 100-04 Medicare claims processing: transmittal 2613, change request 7631. Available at: http://www.cms.gov/Regulations-and-Guidance/ Guidance/Transmittals/downloads/R2613CP. pdf. Accessed March 12, 2013. 2. Pilcher LS. Review of place-of-service coding for physician services processed by Medicare Part B contractors during calendar year 2009 (A-01-10-00516). Available at: https://oig. hhs.gov/oas/reports/region10/11000516.pdf. Accessed January 27, 2013. 3. Greeson TW, Pitts PW. CMS place-of-service instructions continue to confound providers. imagingBiz. Available at: http://www. imagingbiz.com/articles/view/cms-place-ofservice-instructions-continue-to-confoundproviders. Accessed January 27, 2013. 4. American College of Radiology. ACRRBMA joint guidance on CMS’ place of service (POS) coding instructions. Available at: http://www.acr.org/Advocacy/EconomicsHealth-Policy/Billing-Coding/Coding-Source/ Articles/2012-Nov-Dec/Coding-Source-NovDec-2012/POS-Coding-Instruction. Accessed January 27, 2013.
Ezequiel Silva III, MD, South Texas Radiology Group, 8401 Datapoint, Suite 600, San Antonio, TX 78229; University of Texas Health Science Center at San Antonio, Department of Radiology, MC 7800, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900; e-mail: [email protected].