Q: We are coding for an urgent care group that is owned by a hospital and bills on a CMS-1500 for professional services and the UB-04 for facility services. We bill using Place of Service (POS) code 22. Is this correct?
A: Prior to January 1, 2016, the Centers for Medicare and Medicaid Services (CMS) POS code set did not differentiate between an urgent care operating on campus or off campus. As of January 1, 2016, the criteria for outpatient hospital services have changed. If the hospital elects to bill this way, the urgent care should use either POS 22 or POS 19, based on the following:

  • POS -22: On Campus-Outpatient Hospital: A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
  • POS -19: Off Campus-Outpatient Hospital: A portion of an off-campus hospital provider- based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

If your center qualifies to bill the facility fees, the hospital should already have criteria for the codes that they use. These criteria are not specified by CMS, but CMS expects them to form a bell-shaped curve. If the hospital has not adopted these guidelines, the urgent care could modify the suggestions offered by the American College of Emergency Physicians, available at https://www.acep.org/content.aspx?id=30428. 

Q: Can you tell me what services we can bill when they’re provided as a telehealth service?
A: You can find the complete listing of Current Procedural Terminology (CPT) codes for Medicare telehealth services at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.html. The list will include specific CPT and Healthcare Common Procedure Coding System (HCPCS) codes for the following types of service:

  • Professional consultation
  • Office and other outpatient visits
  • Individual psychotherapy
  • Pharmacologic management
  • Advanced care planning
  • Critical care consultations
  • End-stage renal disease (ESRD) related services
  • At least one visit per month must be furnished face-to-face in order to bill for telehealth ESRD services.

Appendix P of the CPT guidelines also offers a list of codes that may be used for synchronous telehealth services.
Effective in 2017, CMS has established Place of Service (POS) 2 as “The location where health services and health-related services are provided or received, through telecommunication technology.” More info about that can be found at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9726.pdf. You must also include modifier -GT, “Via interactive audio and video telecommunications system” or -GQ, “Via an asynchronous telecommunications system” to the appropriate CPT code. For non-Medicare claims, modifier -95, “Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system,” must be attached to the appropriate CPT code.
For example, if you are billing Medicare for a level 3 established patient office visit, you would code 99213 with modifier -GT, using POS 2. If you are billing a commercial payor for the same service, you would code 99213 with modifier -95, using POS 2.

The 2017 Medicare Physician Fee Schedule (MPFS) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-F.html provides a comprehensive explanation of reimbursement and coverage. Along with the POS and modifiers already noted, some of the highlights are as follows:

  • Approved services will be reimbursed at the facility rate
  • The patient receiving the service must be located in a telehealth originating site
    • Originating sites are defined as
      • Rural health professional shortage areas (HPSAs)
      • County that is not included in the metropolitan statistical area (MSA)
    • Interactive technology must be used
      • Two-way, real-time communication between the patient and physician or practitioner
      • An exception is the approved use of asynchronous platforms for the demonstration projects in Alaska and Hawaii
    • The patient and physician or practitioner cannot be at the same site
    • The service must be furnished by a physician or other authorized practitioner
    • The service must be furnished by an eligible telehealth individual

You will also include HCPCS code Q3014, “Telehealth originating site facility fee” on the claim form.

Maximizing Reimbursement for Services on Campus, off Campus, or on the Phone
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