Reporting Place of Service in T-MSIS (Claims)

Brief Issue Description

This document outlines the specifications for reporting the place of service in T-MSIS Other (OT) claims file. The specifications in the guidance provide a detailed explanation on how the data element should be populated to ensure that the place where a service is performed is accurately reported in the state’s T-MSIS file submission.

Background Discussion

Context

In the national standard institutional, professional, and dental electronic 837 claim formats, the setting in which a service was rendered is reported by providers as the Facility Code Value in Loop 2300 (claim header) CLM05-1 and is considered a required data element. In the national standard professional and dental (but not institutional) electronic 837 claim formats providers can also report the service setting in Loop 2400 SV105 if it is different than the service setting reported at the claim header. There is a qualifier reported on these claims that indicates which code set was used to communicate the service setting. Whether a claim is billed in the institutional, professional, or dental format is also a strong indicator of which code set the Facility Code Value represents.

The service setting is reported on institutional claims using the first two characters of the Uniform Billing Claim Form Bill Type code set. The Uniform Billing Claim Form Bill Type code set is maintained by the National Uniform Billing Committee. The service setting is reported on professional and dental claims using Place of Service code set. The Place of Service code set is maintained by the Centers for Medicare and Medicaid Services^[1]. In T-MSIS, the service setting for institutional claims is captured in the T-MSIS IP, LT, and OT files in the claim header data element named TYPE-OF-BILL^[2] and the service setting for professional and dental claims is captured in the T-MSIS OT file in the claim header data element named PLACE-OF-SERVICE.

Challenges

In reporting place of service values in the T-MSIS OT file, states have faced two primary challenges. The first challenge is understanding the difference between an institutional claim Facility Code Value and a professional or dental Facility Code Value on standard electronic claims, particularly if they are stored in the same place in the state’s data system.

The second challenge that states face is determining what to report to T-MSIS if/when the Place of Service code reported by the provider at the claim line level is different than the Place of Service code reported at the claim header level OR if/when special circumstances cause the Place of Service code to only be available at the claim line level or not at all.

CMS Guidance

Only the professional and dental Facility Code Value from standard electronic claims representing a CMS Place of Service code should be mapped to the PLACE-OF-SERVICE field in the T-MSIS OT file. There is a separate data element in the T-MSIS OT file claim header named TYPE-OF-BILL that will capture the entire Uniform Billing Claim Form Bill Type value from providers’ claims for non-inpatient institutional claims (e.g., outpatient hospital, clinic, or home health agency claims).

The PLACE-OF-SERVICE data element on the claim header segment in the OT file should be reported for both fee-for-service claims and managed care encounters. Medicaid agencies and managed care organizations should not hard-code PLACE-OF-SERVICE values. PLACE-OF-SERVICE is a pass-through data element meaning that the state should report the field in T-MSIS as reported by the provider on the claims form.

If the claim is submitted by a provider with the place of service fields blank, then the PLACE-OF-SERVICE on the T-MSIS OT claims file should be blank or space-filled.

If the claim is submitted with the place of service populated with any value other than the valid values listed in T-MSIS data dictionary Appendix A for PLACE-OF-SERVICE values, that value should still be reported in the PLACE-OF-SERVICE data element. 

If the claim is submitted on the 837p electronic claims form and the Facility Code Qualifier is reported with any value other than “B”, then the PLACE-OF-SERVICE value should be blank or space-filled.

If the claim is submitted on the CMS 1450 (UB04) institutional claims form, the PLACE-OF-SERVICE field should be blank or space-filled.

If a Place of Service code is only available at the line level of a claim, PLACE-OF-SERVICE should be populated with one of the place of service values reported at the line level. States should report the place of service on the non-denied claim line with the highest-billed amount. If the highest billed amount are shared by more than two lines on the claim, then the place of service in the claim line with the lowest line number should be reported in the PLACE-OF-SERVICE field.

In table 1 below, an example is provided where a claim is billed in which the claim line details have multiple place of service values.  In the claim, the beneficiary has a brief evaluation and management telehealth consultation with her primary care provider (Place of service valid value of “02”). The beneficiary continues to feel worse and the next hour goes into the doctor’s office, where another evaluation is performed in the office and some medication is administered (Place of service valid value of “11”). The provider includes the services in both locations when the claim is submitted.  When the state populates the PLACE-OF-SERVICE value on the T-MSIS extract for this claim, PLACE-OF-SERVICE valid value of “11” should be reported because the claim line reported with procedure code 99213 has the highest billed amount ($150.00) that is paid.

Table 1 - Claim Line Detail Reported on the Same Claim with Different Place of Service

[1] Updated November 2016: Place of Service Code Set

[2] TYPE-OF-BILL in T-MSIS is a multi-component field that captures more than just the Facility Code Value from an institutional claim.