The Importance of Place of Service (POS) Codes
Place of service (POS) codes are two-digit numeric identifiers used on professional medical claims to specify the location where a service was provided. These codes are vital for several reasons, including setting appropriate reimbursement rates, ensuring compliance with payer policies, and helping to prevent fraud. The Centers for Medicare & Medicaid Services (CMS) maintains the official list of POS codes, and all healthcare providers are required to use them accurately on claims submitted for payment.
For a skilled nursing facility (SNF), which provides inpatient skilled nursing care and related rehabilitative services, the correct POS code is not a one-size-fits-all solution. The determination depends on whether the patient is covered under Medicare Part A for a skilled stay. This distinction is often a source of confusion for billing departments, but understanding the difference is key to a clean claims process.
POS Code 31: Skilled Nursing Facility (Part A Stay)
POS code 31 is designated for a Skilled Nursing Facility, specifically when a patient is receiving services covered under Medicare Part A. This typically applies to patients requiring short-term, intensive care or rehabilitation following a qualifying inpatient hospital stay. Medicare Part A usually covers the first 100 days of a skilled nursing stay, provided the patient meets specific criteria. During this time, a physician or other qualified health professional would use code 31 on their professional claim to reflect the site of service accurately. Misusing this code for a non-Part A patient could result in improper payment or claim denial.
POS Code 32: Nursing Facility (Non-Part A or Long-Term Stay)
In contrast, POS code 32 represents a Nursing Facility, covering a broader range of care settings. This code is used when a patient is a long-term resident of a nursing home or is in a skilled nursing facility but does not have active Medicare Part A coverage for their stay. After a patient's 100 days of Medicare Part A skilled benefits are exhausted, for instance, their billing would likely switch from POS 31 to POS 32, even if they remain in the same physical building. It's crucial for billing teams to track the patient's coverage status closely to ensure the correct code is used at all times. Failure to do so is a common billing error that can lead to audits from CMS.
POS Code Comparison: 31 vs. 32
Distinguishing between POS 31 and POS 32 is essential for medical billing staff. The following table provides a clear breakdown of the differences:
| Feature | POS Code 31 (Skilled Nursing Facility) | POS Code 32 (Nursing Facility) |
|---|---|---|
| Patient Status | Active Part A covered stay, typically for short-term rehabilitation. | Long-term care resident or non-Part A covered stay. |
| Reimbursement | Reimbursement is based on a facility rate, with Part A covering the stay. | Reimbursement is based on a non-facility rate, which can be higher for physicians. |
| Duration | Generally limited to 100 days following a qualifying hospital stay. | Can be indefinite, for chronic or long-term conditions. |
| Billing Context | Used for professional services provided during the skilled, short-term stay. | Used for professional services provided to a patient in a long-term care status. |
| Example | Patient is receiving physical therapy for a hip replacement, covered by Medicare Part A. | Patient is a long-term resident receiving routine physician visits. |
Practical Billing Scenarios and Best Practices
Navigating a Single Facility with Both Care Levels
It is common for a single facility to offer both short-term skilled care and long-term nursing care. For billing purposes, these are treated as distinct settings, even if the patients are on the same floor. The key is to verify the patient's individual status before submitting a claim. Staff should:
- Check with the facility's administration or case management to confirm the patient's current level of care and insurance coverage.
- Utilize an efficient electronic health record (EHR) system that flags changes in patient status.
- Conduct regular audits of billing to catch and correct mismatched POS codes.
Consequences of Incorrect Coding
Submitting claims with the wrong POS code can have serious consequences. If a provider incorrectly uses POS 32 for a patient with a Medicare Part A skilled stay, it could lead to overpayment issues and potentially trigger a CMS audit. Conversely, using POS 31 for a non-covered stay could result in a claim denial. Both scenarios cause administrative headaches and can negatively impact the provider's revenue cycle.
The Role of Clear Communication
Accurate billing in a skilled nursing setting requires clear communication among all parties involved. This includes the physician providing the service, the facility's administrative staff, and the billing department. For instance, a physician performing a routine visit must know if the patient is under a covered Part A stay or in a long-term care status. Robust internal procedures for verifying patient coverage and communicating changes can significantly reduce the risk of coding errors.
Conclusion: The Final Word on SNF POS Codes
Ultimately, there is no single place of service code for skilled nursing homes. Instead, the correct code is dependent on the patient's specific circumstances. POS code 31 is for a patient with a Medicare Part A covered skilled nursing stay, while POS code 32 is for patients in a nursing facility who do not have a covered Part A stay. By understanding this distinction and implementing rigorous verification protocols, healthcare providers can ensure billing accuracy, maximize reimbursement, and maintain compliance with CMS regulations. For further clarification and the complete list of codes, always refer to official CMS resources.
Official CMS Place of Service Code Set
The Ever-Evolving Landscape of Medical Coding
It is also important to remember that CMS periodically updates its codes and guidelines. Staying current with these changes is a continuous process for any practice billing to Medicare or other health plans. Regular training for billing staff and leveraging technology to automate code checks can help prevent errors caused by outdated information. An audit trail of patient coverage status is a valuable asset in the event of a review. For more complex cases or ambiguous situations, consulting with a certified professional coder is a recommended best practice.
