Wiki Home or Residence Services with POS 13 for Assisted Living

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CruzMich

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(This is for a Family Practice - Professional Billing) As of Jan 1, 2023 the AMA Deleted all Assisted Living CPT codes. Per mlnMATTERS MM13004 - We are to bill Assisted Living patients with the Home Services codes and with the correct place of service (13) for our Assisted Living patients. UHC Medicare Advantage Plans have denied ALL claims. I have sent for reconsideration and they upheld the original decision. I am reaching out to find out if anyone is familiar with this situation or understand what United Healthcare is doing? I know when I billed for Home Health UHC was NEVER on board with the Medicare guidelines until at least May. Our office is in OK. Not one person with UHC can answer any of my questions. I have been billing for over 30 years.
 

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I don't know the answer to your question, but I can offer a possible explanation.

I am thinking this might be similar to the observation/inpatient updates for 2023, where the insurances (and MACs) had not updated their systems for the new billing guidelines (using different POS with the inpatient codes).

Hopefully, someone else can offer a more specific answer.
 
lgardner said:
I don't know the answer to your question, but I can offer a possible explanation.

I am thinking this might be similar to the observation/inpatient updates for 2023, where the insurances (and MACs) had not updated their systems for the new billing guidelines (using different POS with the inpatient codes).

Hopefully, someone else can offer a more specific answer.
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I am hoping that is what is happening. UHC is NEVER on board until spring.
 
I'm having issues as well with "NEW" Assisted Living Codes for the 2023 being but in HOLDing for place of service (13) being incompatible. I'm trying to figure out if you should now use the place of service code (12) since the CPT codes are now residential.
 
kpettit2022 said:
I'm having issues as well with "NEW" Assisted Living Codes for the 2023 being but in HOLDing for place of service (13) being incompatible. I'm trying to figure out if you should now use the place of service code (12) since the CPT codes are now residential.
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Please read the mlnMATTERS I have attached. For Assisted Living you would use pos 13. That is the correct POS. I am appealing my claims slowly and they are approving my appeals. UHC FINALLY approved an appeal. Humana is paining along with Aetna. The MACs were not ready.
 
Thank you so much for the info. I thought I was correct with using POS 13 but didnt understand why they were having issues. I did look at my claims a little closer after reading this feed and it was UHC giving me problems. I will start appealing them tomorrow as well.
 
midnight1995 said:
Is any one also have the same issue with Aetna
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I did have issues with Aetna at first. They started to pay so I ran a report to look up the accounts that were paid to confirm those were Medicare Advantage plans. In my appeal I would reference the claims that were paid with the same code and the same product segement. So a PPO payment I would match to another PPO that was denied and appeal using that claim no as a reference. I did the same when it was an HMO etc. I appeal through Availity. Claim submitted with a copy of mlnMATTERS by CMS for my supporting documentation. I appeal with my verbiage, attach mlnMATTERS, reference a paid claim if you can. It should be a claim that matches your situation. Same insurance, same product segment, same code if you can. If a modifier was used I find another claim with the modifier. When there is no claim to reference, I clearly state what took place. Starting with the AMA removed all Assisted Living CPT E/M codes as of 1/1/2023. (List the codes)
 
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I am having the same issue with Humana as well. Will try and give the appeal process a try since we can't seem to find anyone state side to assist. Thank you for sharing this information.
 
I have successfully appealed with UHC, Aetna and Humana. These were naturally the three culprits. They are updated. Please reference MLN MATTERS MM13004. UHC does not allow to download the MLN MATTERS by CMS because it has punctuation in it. (Strange). I distinctly spell it out in my verbiage and I reference MLN Matters MM13004. This explains it all. This explains the POS that may be billed with the NEW Home Visit Family. If you have any questions, reach out.
 
Question: I understand the POS 12 vs 13 but cannot find direction on the appropriate address and NPI that needs to be billed out in box 32a of the CMS 1500 when using POS 13. Any thoughts? Do we use the provider group address and NPI or the assisted living facilities address and NPI?

Any help would be appreciated
 
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