POS - Place of Service Codes

Code(s)	Place of Service Name
1	Pharmacy
2	Unassigned
3	School
4	Homeless Shelter
5	Indian Health Service Free-standing Facility
6	Indian Health Service Provider-based Facility
7	Tribal 638 Free-standing Facility
8	Tribal 638 Provider-based Facility
9-10	Prison/ Correctional Facility
11	Office Visit
12	Home Visit
13	Assisted Living Facility
14	Group Home *
15	Mobile Unit
16	Temporary Lodging
17-19	Unassigned
20	Urgent Care Facility
21	Inpatient Hospital Visit
22	Outpatient Hospital Visit
23	Emergency Room Hospital
24	Ambulatory Surgical Center
25	Birthing Center
26	Military Treatment Facility
27-30	Unassigned
31	Skilled Nursing Facility
32	Nursing Facility
33	Custodial Care Facility
34	Hospice
35-40	Unassigned
41	Ambulance - Land
42	Ambulance  Air or Water
43-48	Unassigned
49	Independent Clinic
50	Federally Qualified Health Center
51	Inpatient Psychiatric Facility
52	Psychiatric Facility-Partial Hospitalization
53	Community Mental Health Center
54	Intermediate Care Facility/Mentally Retarded
55	Residential Substance Abuse Treatment Facility
56	Psychiatric Residential Treatment Center
57	Non-residential Substance Abuse Treatment Facility
58-59	Unassigned
60	Mass Immunization Center
61	Comprehensive Inpatient Rehabilitation Facility
62	Comprehensive Outpatient Rehabilitation Facility
63-64	Unassigned
65	End-Stage Renal Disease Treatment Facility
66-70	Unassigned
71	Public Health Clinic
72	Rural Health Clinic
73-80	Unassigned
81	Independent Laboratory
82-98	Unassigned
99	Other Place of Service

Waterproof Casting Material Billing guidelines

Florida Medicaid billing guidelines for Waterproof casting Material,

• Bill with HCPCS code A4590, one unit
• Applies to Pediatric recipients, ages 0-20
• Billing will no longer require submission of medical documentation or invoice
• A flat fee of $ 15.00 will be reimbursed, regardless of size or number of rolls used
• Limited to orthopedic providers in the office setting ( POS 11 )
  

Debridement Coding 2011

 2011 Changes in Debridement Coding

• Surgical wound debridement codes 11040 and 11041 are deleted. Report 97597 and 97598 for debridement of epidermis or dermis
• Debridement is now coded based on depth and diameter
• The debridement codes were modified to provide a method of reporting for the more extensive debridement procedures required for MRSA and other complex wound infections  
• For multiple wounds of the same depth, report the combined sum of the surface area debrided
• For multiple wounds of different depths, report sums of “different depth” debridement procedures
• Use the 59 modifier for different depth wound debridements (11042, 11045 or 11044 at same surgical session)

2011 Debridement Codes

• 11042 – debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less
• 11045 – each additional 20 sq cm, or part thereof (add on code to be listed in addition to code for primary procedure)
• 11043 – debridement, muscle and fascia (includes epidermis and dermis, and subcutaneous tissues, if performed); first 20 sq cm or less
• 11046 – each additional 20 sq cm, or part thereof (add on code to be listed in addition to code for primary procedure)
• 11044 – debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less
• 11047 – each additional 20 sq cm, or part thereof (add on code to be listed in addition to code for primary procedure)

Debridement Documentation

Documentation is the key to appropriate code selection. The depth of debridement, manner of debridement, presence of gross contamination and the tissues involved in the debridement or depth of debridement  drive the coding choice.


Debridement procedure notes should include documentaion of the :

• Type of debridement (excisional, non excisional)
• Depth of tissue debrided (skin and subcutaneous, soft tissue, muscle, bone)
• Instrument (s) used to perform the debridement
• Associated diagnosis; if ulcer, document type of ulcer (diabetic, pressure, etc.)
• The nature of the tissue removed ( slough, necrosis, devitalized tissue, non-viable tissue, etc.)
• The appearance and size of the wound

Appeals of Claims decisions

Once an initial claim determination is made, providers, participating physicians, and other suppliers have the right to appeal. Physicians and other suppliers who do not take assignment on claims have limited appeal rights.

Medicare offers five levels in the Part A and Part B appeals process. In addition, minor errors or omissions on certain Part B claims may be corrected outside of the appeals process using a process known as a clerical reopening.

The five levels of appeals, listed in order, are:

Appeal level	Time limit for filing request	Where to file an appeal
First level: Redetermination	120 days from the initial claim determination	Medicare administrative contractor (MAC)
Second level: Reconsideration	180 days from the redetermination decision	Qualified independent contractor (QIC)
Third level: Administrative law judge hearing (ALJ)	60 days from the date of the reconsideration decision * Monetary threshold for requests made on or after January 1, 2010: $130	Office of Medicare Hearings and Appeals
Fourth level: Medicare Appeals Council	60 days from the date of the ALJ decision	Departmental Appeals Board
Fifth level: Judicial review	60 days from the date of the Medicare Appeals Council decision * Monetary threshold for requests made on or after January 1, 2010: $1,260	Federal District Court

* Monetary threshold (also known as the amount in controversy or AIC), is the dollar amount required to be in dispute to establish the right to a particular level of appeal. Congress establishes the amount in controversy requirements. The amount in controversy required when requesting an administrative law judge hearing or judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers.

 

Part B clerical reopening

A clerical error could occur when one of the following happens to your claims:

• Mathematical or computational mistakes

• Transposed procedure or diagnostic codes

• Inaccurate data entry

• Misapplication of a fee schedule

• Computer errors

• Denial of claims as duplicates which party believes incorrectly identified as duplicate

• Incorrect data items such as provider number, modifier, date of service

There are two options for conducting a clerical reopening of a claim:

• Telephone reopening requests via the interactive voice response (IVR) allows providers/customers to request telephone reopenings on certain claims.

 

First level of appeal: Redetermination

A redetermination is an examination of a claim by fiscal intermediary (FI), carrier, or MAC personnel who are different from the personnel who made the initial claim determination. The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file an appeal. A redetermination must be requested in writing. A minimum monetary threshold is not required to request a redetermination.

Second level of appeal: Reconsideration

A party to the redetermination may request a reconsideration if dissatisfied with the redetermination decision. A qualified independent contractor (QIC) will conduct the reconsideration. The QIC reconsideration process allows for an independent review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration.

Third level of appeal: Hearing by an administrative law judge (ALJ)

If at least $120 remains in controversy following the qualified independent contractor's (QIC's) decision, a party to the reconsideration may request an administrative law judge (ALJ) hearing within 60 days of receipt of the reconsideration decision. Appellants must send notice of the ALJ hearing request to all parties to the QIC for reconsideration. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA).

 

Fourth level of appeal: Review by the Medicare Appeals Council

If a party to the an ALJ hearing is dissatisfied with the ALJ's decision, the party may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy. The request for Medicare Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ's decision, and must specify the issues and findings that are being contested. 

The resources below are external to the FCSO and CMS Web sites, but are being offered for your convenience. FCSO and CMS are not responsible for the content or maintenance of these external sites.

 

Fifth level of appeal: Judicial review

If $1,260 or more is still in controversy following the Medicare Appeals Council's decision, a party may request judicial review before a Federal District Court judge. The appellant must request a Federal District Court hearing within 60 days of receipt of the Medicare Appeals Council's decision.

• The Medicare Appeals Council's decision will contain information about the procedures for requesting judicial review.

 

Additional resources

Within the FCSO and CMS Web sites you will find information related to the five levels in the Part A and Part B appeals process.

CMS links

• CMS Appeals Web resources

CMS resource materials available for download

• MLN - The Medicare Appeals Process Brochure

CMS Internet-only manuals: Publication 100-04

• Chapter 29 – Appeals of Claims Decisions

• Chapter 34 – Reopening and Revision of Claim Determinations and Decisions

Source CMS