WellCare is implementing the following policy for Appropriate Place of Service (POS) Billing (IH146) with an effective date as of November 26, 2020.
Summary of policy:
According to CMS, facility or non-facility rate that a physician service is paid under the Medicare Physician Fee Schedule (MPFS) is determined by the Place of Service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier.
In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or non-facility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes 19 or 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred.
What does this mean for providers?
The Place of Service policy will address the reimbursement of Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes that are reported in a place of service (POS) considered inappropriate based on the code’s description or available coding guidelines when reported by a physician or other health care professional.
Providers may receive an IH146: “Denied: Place of Service Not Consistent with Claim History” claim denial if any service (other than inpatient care) is billed by any professional provider on the same date of service as inpatient care but with a different place of service, when the member also received inpatient care the previous day and was not discharged on the same day, or on the subsequent day.
Providers may also receive an IH146 denial for services billed in place of service 19 (Outpatient Hospital - Off campus), 22 (Outpatient Hospital - On campus) or 23 (Emergency Room - Hospital) by any professional provider on the same date of service as inpatient care, when the member also received inpatient care the previous day and was not discharged.
Providers may receive an IH146: “Denied: Place of Service Not Consistent with Claim History” claim denial for any physician service code when billed in Place of Service 11 (Office) by a professional provider and the same code was billed by any outpatient hospital for the same date of service.
WellCare will reimburse CPT and HCPCS codes when reported with an appropriate Place of Service (POS) code. WellCare aligns with CMS POS Code set, which are two-digit codes submitted on the CMS 1500 claim form or its electronic equivalent to indicate the setting in which a service was provided.
Providers can review the complete policy at www.wellcare.com/providers, select your state, select Claims, then Payment Policy.
We are here to help. Please contact your Network Representative for general inquiries regarding this program.
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