Are You Applying These New & Revised POS Modifiers on Your Claims?
Reduction in Payment for New Off Campus Provider-Based Clinics.
If you work for providers offering services in clinics, provider-based or hospital-based off-campus, these newly-introduced and revised POS modifiers could play a key role in the claims process. Section 603 of the Bipartisan Budget Act of 2015 mentions a reduction in reimbursement for ‘new’ off campus provider-based clinics, and this has taken the hospital community by surprise.
Are you in Sync with the Latest HCPCS Level II codes and Modifiers?
You will use the PO HCPCS modifier with every code for outpatient hospital services provided in an off-campus PBD of a hospital. The reporting of this new modifier has become mandatory effective January 1, 2016.
Note: This modifier cannot be used for remote locations of a hospital/satellite facilities of a hospital/services for services provided in ED.
Updates to POS 19 & 22
Providers can heed this. The existing POS code set introduces new POS code 19 for Off Campus Outpatient Hospital and revises POS code 22 language to ‘On Campus Outpatient Hospital (previously ‘Outpatient Hospital’). Both these indicators will affect the SOS differential in RBRVS that will lead to decrease in physician, professional payment. Local contractors will create policies as required to adjudicate claims containing new POS code 19 and revised POS code 22 as per Medicare national policy, and treat both the modifiers in the same way. Moreover, the three-day payment window applies to services billed with POS code 19 as well.
Collect Provider-Based Clinic Data, Says CMS
The Centers for Medicare and Medicaid (CMS) also wants to start gathering data relative to these clinics, and most likely, other off-campus provider-based operations. Note that hospitals also have provider-based clinics on-campus and often inside the hospital. The agency is keen on finding out whether such provider-based operations are more expensive as compared to their freestanding counterparts. This is because OIG has always emphasized that payments for provider-based clinics and freestanding clinics should be equivalent. What’s more, MedPAC has also pointed out that reimbursement should be same for E/M codes.
Note that CMS is collecting information on provider-based clinics supposedly because of the pressure coming in from OIG and MedPAC.
Keeping track of HCPCS code changes and modifiers and understanding the intricacies of the latest changes can take you a lot of your time. That’s why you need a good resource such as The Coding Institute’s HCPCS Level II code book to show you the way.