We are having a problem with United Health Care and the question seems to arise out modfiers -31 vs -32. We did submit a question last week, and we think we understand the difference between the two modifiers but are still unsure how to proceed. The facility is a nursing home with a wide age range since a number of residents are younger with post CVA, drug-related illnesses etc. Many are discharged from a hospital initially (or along the course of their stay) but remain at the facility for their remaining lives. If someone is discharged to this facility, does their care always remain -31 modifier or return (or change to -32) after 100days? We see them for regular care and might for years after their hospitalization. Are we able to go back and rebill the services that have been reduced in reimbursement due to the takeback, or are we "stuck?" Are others having problems with UHC or just us?
It seems the question means to refer to Place of Service 31 and 32, not "Modifier" 31 and 32. If that is correct, the following response applies.
Use Place of Service 31 if the patient is under a Part A skilled nursing stay. Use Place of Service 32 if the patient is under a Part B long term stay.
Place of Service 31 – Skilled Nursing Facility: A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
Place of Service 32 – Nursing Facility - A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than individuals with intellectual disabilities.
Reference: https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-sets
When seeing most patients in a nursing facility, practitioners must determine if the patient is under a long term Medicare Part B stay or a Part A skilled nursing facility stay. The reason this determination must be made is it changes the place of service code on the claim form. If the patient is under a long term Part B stay, Place of Service 32 must be used on the claim form. If the patient is under a Part A skilled nursing facility stay, Place of Service 31 must be used on the claim form.
This can be challenging because there may be patients under a Place of Service 32 Part B Stay and patients under a Place of Service 31 Part A Stay in the same building.
APMA provides guidance on this for members here: https://www.apma.org/practice-management/coding-resources/coding-correctly-for-patients-in-nursing-homes/
A skilled nursing facility stay for Medicare beneficiaries is typically an inpatient rehabilitation stay following a qualifying inpatient hospital stay that was at least 3 days. Skilled nursing facility stays can normally be a maximum of only 100 days.
If a patient starts a skilled nursing facility stay, their stay does not remain as skilled forever. The skilled care is normally capped at 100 days. Typically if a patient starts a skilled stay (POS 31) and remains in the same facility after 100 days, the stay changes to a long term stay (POS 32). In this situation, the provider needs to know when this happens and change the Place of Service on their claim form from POS 31 to POS 32.
How you handle claims that have been submitted with the incorrect place of service differs based on the payer. Different payers may have different answers to this. There is not one answer that applies to all payers. The suggestion is to check with the payer to see how to best handle that situation.
Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Certified Professional Coder
Certified Professional Medical Auditor
Lehrman Consulting, LLC