CMS’ latest guidance reiteration will, hopefully, make coding these sometimes-confusing services easier.

Determining the date of service (DOS) when reporting a medical claim seems straightforward, but the Centers for Medicare & Medicaid Services (CMS) recently-released “Guidance on Coding and Billing Date of Service on Professional Claims,” is a good indication this topic is more complex than it appears. The provider education article (MLN Matters SE17023) reiterates existing CMS policy regarding DOS. That is, CMS is not introducing new guidelines, but has taken the time to remind us of what we should have been doing all along (and should continue to do). This suggests they might be seeing an uptick in errors related to DOS selection — particularly in the following areas.

Radiology Services

The technical component (TC) of a radiology service “is billed on the date the patient had the test performed,” per MLN Matters SE17023. By contrast, “… the date of service for the professional component [PC] would be the date the review and interpretation is completed.” “When billing a global service [in other words, both the TC and PC of a radiology service], the provider can submit the professional component with a date of service reflecting when the review and interpretation is completed or can submit the date of service as the date the technical component was performed,” per MLN Matters SE17023.

Pathology Services

As with radiology services, surgical and anatomical pathology services may have both a PC and a TC, as indicated by a PC/TC indicator “1” on the Medicare Physician Fee Schedule (MPFS) Relative Value File. Per CMS, the DOS for the TC is the date the specimen was collected (e.g., the surgery date) and the DOS for the PC is the date the review and interpretation are completed. The DOS rule for billing global pathology services is the same as for radiology, with an exception: “When the collection spans two calendar dates, use the date the specimen collection ended,” per CMS. Exceptions also apply for stored specimens:

  • In the case of a test/service performed on a stored specimen, if a specimen was stored for less than or equal to 30 calendar days from the date it was collected, the DOS of the test/service must be the date the test/service was performed only if:
  • The test/service is ordered by the patient’s physician at least 14 days following the date of the patient’s discharge from the hospital;
  • The specimen was collected while the patient was undergoing a hospital surgical procedure;
  • It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
  • The results of the test/service do not guide treatment provided during the hospital stay; and

The test/service was reasonable and medically necessary for treatment of an illness. If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the DOS of the test/service must be the date the specimen was obtained from storage.

Care Plan Oversight (CPO)

To report CPO services, providers must perform and document 30 or more minutes of physician supervision of a patient, per month. Per CMS, “The claim for CPO must not include any other services and is only billed after the end of the month in which CPO was provided. The date of service submitted on the claim can be the last date of the month or the date in which at least 30 minutes of time is completed.”

Home Health Certification and Recertification

The proper DOS for the certification is the date the qualified provider completes and signs the plan of care. The DOS for the recertification is the date the qualified provider completes the review.

Physician End-stage Renal Disease (ESRD) Services

For ESRD services, MLN Matters SE17023 specifies:

  • The DOS for a patient beginning dialysis is the date of their first dialysis through the last date of the month.
  • For continuing patients, the DOS is the first through the last date of the month.
  • For transient patients or less than a full month service, these can be billed on a per diem basis. The DOS is the date of responsibility for the patient by the billing physician. This would also include when a patient dies during the month.

When submitting a DOS span for the monthly capitation procedure codes, the day/units should be coded as “1.”

Transitional Care Management (TCM)

The DOS for TCM is the date the practitioner completes the required face-to-face visit. “Keep in mind,” CMS reminds us, “there are additional services to be provided during the 30-day period.”

Clinical Laboratory Services

As with pathology, the usual DOS for clinical laboratory services is the date the specimen is collected, but if the collection spans more than one day, the DOS is the date the collection ends. MLN Matters SE17023 enumerates three exceptions to these rules:

  1. In the case of a test/service performed on a stored specimen, if the specimen was stored less than or equal to 30 calendar days from the date it was collected, the date of service of the test/service must be the date the test/service was performed only if:
  • The test/service was ordered by the patient’s physician at least 14 days following the date of the patient’s discharge from the hospital;
  • The specimen was collected while the patient was undergoing a hospital surgical procedure;
  • It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
  • The results of the test/service do not guide treatment provided during the hospital stay; and
  • The test/service was reasonable and necessary for the treatment of an illness.

If the specimen was stored for more than 30 calendar days before testing, the specimen is considered to have been archived and the date of service of the test/service must be the date the specimen was obtained from storage.

  1. In the case of a chemotherapy sensitivity test/service performed on live tissue, the date of service of the test/service must be the date the test/service was performed only if:
  • The decision as to the specific chemotherapy agent to test is made at least 14 days after discharge;
  • The specimen was collected while the patient was undergoing a hospital surgical procedure;
  • It would be medically inappropriate to have collected the sample other than during the hospital procedure for which the patient was admitted;
  • The results of the test/service do not guide treatment provided during the hospital stay; and
  • The test/service was reasonable and medically necessary for the treatment of an illness.
  1. In the case of a molecular pathology test or a test designated by CMS as an advanced diagnostic laboratory test (ADLT) (defined in 42 CFR 414.502), the date of service must be the date the test was performed only if:
  • The test was performed following a hospital outpatient’s discharge from the hospital outpatient department;
  • The specimen was collected from a hospital outpatient during an encounter;
  • It was medically appropriate to collect the sample from the hospital outpatient during the hospital outpatient encounter;
  • The results of the test do not guide treatment provided during the hospital outpatient encounter; and
  • The test was reasonable and necessary for the treatment of an illness.

Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring

The DOS for G0248 Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient’s ability to perform testing and report results, which describes the initial demonstration use of home INR monitoring and instructions for reporting, is the date the demonstration and instructions for reporting are given in a face-to-face setting with the patient. The DOS for G0249 Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests, which describes the provision of test materials and equipment for home INR monitoring, is the date the test materials and equipment are given to the patient. Code G0250 Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include 4 tests, which describes the physician review, interpretation, and patient management of home INR testing, is payable once every four weeks. The DOS is the date of the fourth test interpretation. The DOS for 93793 Anticoagulant management for a patient taking warfarin must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed, which describes the physician interpretation and instructions, is the date of the review.