Laboratory claims denied in error per revisions/clarifications for correct place of service (POS) code assignment

CMS released change request (CR) 7631 Revised and Clarified Place of Service (POS) Coding Instructions to be implemented and effective for dates of service on or after April 1, 2013. The CR revises/clarifies that all services – with two exceptions – paid under the Medicare physician fee schedule (MPFS) are to be billed with the POS as the same setting in which the beneficiary received the face-to-face encounter. The CR also explains that for services that include a professional component (PC) and technical component (TC), the POS code assigned for the PC will be the setting in which the beneficiary received the TC.

Due to the clarifications provided in CR7631, First Coast identified claims that denied incorrectly:

• Claims billed by independent laboratories for the professional component of certain laboratory and/or pathology codes have denied in error when billed with POS codes: Inpatient hospital (21), Outpatient hospital (22) , Emergency room-hospital (23), Inpatient psychiatric facility (51), Psychiatric facility – partial hospitalization (52), Comprehensive inpatient rehabilitation facility (61) or Comprehensive outpatient rehabilitation facility (62).

• Claims billed by independent laboratories for certain laboratory and/or pathology codes have denied when billed with POS office (11)

• Claims billed by physicians for the PC of certain laboratory and/or pathology codes have denied in error when billed with POS independent laboratory (81)

First Coast’s claims processing system has been updated to no longer deny the claims for the situations mentioned above. No provider action is necessary as First Coast will adjust the claims that processed on or after April 1, 2013, and denied in error.

MAC J9 which includes Puerto Rico, the U.S. Virgin Islands and Florida