11/03/2023    New York Codingline Subscriber

Medicare Overpayments and POS

This is not a situation where just a few physicians
are being audited for billing nursing facility care
using the incorrect Place of Service (POS) code.
This is becoming a national situation where all 7
Medicare Administrative Carries (ie. MACs) are
auditing physicians and are requesting the return
of the reimbursements that were inappropriately
paid for billing Place of Service code 32 instead
of Place of Service code 31. The MACs are going
back as far as 2018 to audit the physicians’
medical records and are demanding the return of the
incorrectly reimbursed claims.

Place of Service code 31 is defined as: SKILLED
NURSING FACILITY: A facility that provides
inpatient skilled nursing care and related services
to patients who require medical, nursing, or
rehabilitative services but does not provide the
level of care or treatment available in a hospital.

Place of Service code 32 is defined as: NURSING
FACILITY: A facility which primarily provides
skilled nursing care and related services for the
rehabilitation of injured, disabled, or sick
persons, or, on a regular basis, health related
care services above the level for custodial care to
other than mentally challenged individuals.

Use POS 31 when the patient is in a skilled nursing
facility (SNF), which is a short-term
care/rehabilitation facility. Use POS 32 when the
patient is in a long-term nursing care facility.
Keep in mind that one facility can provide BOTH
types of care. There is usually not a separate
portion of the nursing home that is defined as a
skilled nursing facility, nor is there a separate
portion of the nursing home that is defined as
nursing facility. It is not about where the patient
is located. It is about the type of care that the
patient is receiving. Therefore, it is imperative
in advance of treatment of the patient to obtain
from the nursing home whether the patient is being
treated as a Place of Service code 31 patient or is
being treated as a Place of Service code 32
patient. The nursing home cannot say they don’t
know. How do you think that they are being paid?

Place of Service code 31 reimburses at a lower rate
than Place of Service code 32 reimburses. That is
why you need to know the correct POS code of the
patient being treated in advance of treatment.
Unfortunately, this is not on the nursing home.
This is on the physician that is providing the
service(s). Remember, it is the provider’s
information that goes on the CMS-1500 Claim Form or
the electronic equivalent. The facility is merely
where the service is being provided.

What is one to do when the provider receives a
request for money to be paid back to the MAC? If
you have malpractice insurance, it is imperative to
contact them as soon as possible to find out if you
have administrative defense coverage. If you do not
have administrative defense coverage, it is
imperative to contact a healthcare attorney to be
represented in this situation. It is not a good
idea for the provider to speak with the
representative of the MAC that is in the letter
requesting reimbursement. Anything you say can be
held against you.

Michael G. Warshaw, DPM, CPC, Lady Lake, FL

Other messages in this thread:

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11/03/2023    New York Codingline Subscriber

Medicare Overpayments and POS

We received a request for money to be paid back to
Medicare. The reason is the place of service (POS)
was incorrect for claims from 2018. First of all we
are surprised by how far back they have gone. How
do we actually determine what is the correct POS
when the facility is both a nursing home and a
skilled nursing facility (SNF)?

New York Codingline Subscriber

This is not a situation where just a few physicians
are being audited for billing nursing facility care
using the incorrect Place of Service (POS) code.
This is becoming a national situation where all 7
Medicare Administrative Carries (ie. MACs) are
auditing physicians and are requesting the return
of the reimbursements that were inappropriately
paid for billing Place of Service code 32 instead
of Place of Service code 31. The MACs are going
back as far as 2018 to audit the physicians’
medical records and are demanding the return of the
incorrectly reimbursed claims.

Place of Service code 31 is defined as: SKILLED
NURSING FACILITY: A facility that provides
inpatient skilled nursing care and related services
to patients who require medical, nursing, or
rehabilitative services but does not provide the
level of care or treatment available in a hospital.

Place of Service code 32 is defined as: NURSING
FACILITY: A facility which primarily provides
skilled nursing care and related services for the
rehabilitation of injured, disabled, or sick
persons, or, on a regular basis, health related
care services above the level for custodial care to
other than mentally challenged individuals.

Use POS 31 when the patient is in a skilled nursing
facility (SNF), which is a short-term
care/rehabilitation facility. Use POS 32 when the
patient is in a long-term nursing care facility.
Keep in mind that one facility can provide BOTH
types of care. There is usually not a separate
portion of the nursing home that is defined as a
skilled nursing facility, nor is there a separate
portion of the nursing home that is defined as
nursing facility. It is not about where the patient
is located. It is about the type of care that the
patient is receiving. Therefore, it is imperative
in advance of treatment of the patient to obtain
from the nursing home whether the patient is being
treated as a Place of Service code 31 patient or is
being treated as a Place of Service code 32
patient. The nursing home cannot say they don’t
know. How do you think that they are being paid?

Place of Service code 31 reimburses at a lower rate
than Place of Service code 32 reimburses. That is
why you need to know the correct POS code of the
patient being treated in advance of treatment.
Unfortunately, this is not on the nursing home.
This is on the physician that is providing the
service(s). Remember, it is the provider’s
information that goes on the CMS-1500 Claim Form or
the electronic equivalent. The facility is merely
where the service is being provided.

What is one to do when the provider receives a
request for money to be paid back to the MAC? If
you have malpractice insurance, it is imperative to
contact them as soon as possible to find out if you
have administrative defense coverage. If you do not
have administrative defense coverage, it is
imperative to contact a health care attorney to be
represented in this situation. It is not a good
idea for the provider to speak with the
representative of the MAC that is in the letter
requesting reimbursement. Anything you say can be
held against you.

Michael G. Warshaw, DPM, CPC, Lady Lake, FL