From specimen collection to maternity packages, inspect coding and billing DOS rules.
On Sept. 19, 2017, the Centers for Medicare & Medicaid Services (CMS) released MLN Matters® article SE17023 for physician and non-physician practitioners who submit claims on either the CMS-1500 form or electronically via the X12 837 Professional Claim to Medicare administrative contractors (MACs) for Part B service charges. The MLN Matters article does not offer new guidance, but reiterates how to represent the date of service (DOS) on Part B outpatient provider claims. It also reminds providers, “Expenses are considered to have been incurred on the date the beneficiary received the item or service, regardless of when it was paid for or ordered.”
On Oct. 2, 2017, CMS rescinded this publication with the warning, “This article may be re-issued at a later date.” CMS offered no explanation regarding why the article was rescinded. Regardless, this information is important because it represents an educational outreach provided by CMS (which often occurs at the behest of the MACs or the Office of Inspector General (OIG), who have performed claim audits). A quick review of the article is warranted.
DOS when Services Last More than One Day
Services that span more than one date might include, for example:
- Anesthesia when the administration continued to the next date
- A teaching physician sees the patient on the day following a late-night resident service.
- Mohs surgery when the service must continue on a different date (usually due to the patient’s inability to tolerate the entire procedure in one day)
In these cases, the DOS is the day the service concluded.
Radiology services typically have two components: professional and technical. The technical component is billed on the date the patient received the service. Professional claims for “reading” are billed the day the physician provided the interpretation and report. The two dates of service may not match.
Surgery and anatomical pathology services also have two components. The technical component is billed on the date the specimen is collected (e.g., the date of surgery/biopsy). The professional component is billed on the date the physician interprets and creates the report. Each service is billed on the date it occurs, even if those dates are not the same.
If the specimen collection spans multiple days, use the DOS the collection is completed.
The rules differ for stored specimens. If the test is performed on a stored specimen (stored less than or equal to 30 days), the DOS must be the date the test was performed only if:
- The patient’s physician orders the test at least 14 days following the date of the patient’s discharge from the hospital.
- The specimen is collected while the patient was undergoing a hospital procedure.
- It would be medically inappropriate to have collected the specimen other than during the hospital procedure for which the patient was admitted (i.e., surgical biopsy performed incidentally to the reason for surgery).
- The results of the test do not guide treatment provided during the hospital stay.
- The test is reasonable and medically necessary for treatment of illness or injury.
Per the Medicare Benefit Policy Manual, Chapter 15, Section 20, “If the test is ordered on a specimen stored more than 30 days, the date of service for the technical service is the date the specimen is retrieved from storage. The professional component is billed on the date the physician provided the interpretation and report (include appropriate modifiers).”
Care plan oversight (CPO), home health certification/recertification, and transitional care management (TCM) claims are billed on the date the physician provided supervision or completed the plan of care. For example, CPO and TCM are billed once per month. The DOS on the claim should be the date the physician provided the 30 minutes of supervision. The physician should legibly sign and date the documentation.
Physician end-stage renal disease services are provided either daily or monthly. When billing a monthly capitated rate, the DOS is the first through the last day of the month. For transient patients, or less than a full month, bill the DOS per diem. The DOS is the date the billing physician becomes responsible for the patient. This includes instances when a patient expires during the month.
Diagnostic psychological and neuropsychological testing (96101 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report and 96127 Brief emotional/behavioral assessment (eg depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument) represents services that may be performed during multiple sessions, on different dates. The appropriate DOS is the day when the service(s) (based on CPT® code description) is concluded. The clinical documentation should reflect both the start and end date of the services. The same logic applies to psychiatric testing provided over multiple days.
A practitioner receiving the post-operative transfer of care submits post-operative services using the appropriate surgical procedure code with modifier 55 Postoperative management only appended (and indicating the date of surgery). The operating surgeon transferring care reports the CPT® surgical code(s) with modifier 54 Surgical care only appended.
Maternity services are bundled using the appropriate CPT® code for the maternity package. Use the date of delivery/termination as the DOS. Charges for services unrelated to the delivery should be billed using the DOS the service was provided.
When documentation is requested to support any of the above services, be sure to submit all dates that encompass the full service (beginning, interim, and conclusion). Otherwise, auditors might misconstrue CPT® code selection.