POS 61 in Medical Billing
POS 61 indicates a Comprehensive Inpatient Rehabilitation Facility. Such facilities admit patients for rehabilitation after serious ailments such as stroke, spinal cord injury, brain injury, amputation, or major surgery.
It indicates that services were actually provided in an interior setting that focuses primarily on providing intensive rehabilitation services, as are structured facilities designed to provide coordinated care involving physical therapy, occupational therapy, speech therapy, and rehabilitation nursing.
The defining characteristic of POS 61 is that it is neither a general hospital nor nursing home. Short-term, highly focused rehabilitation is meant in such a special setting. Therefore, medical billing must reflect the intensity and purpose of care provided in POS 61 in order to ensure that claims are processed appropriately.
Services Billed Under POS 61 in Medical Billing
Under the POS 61 category, treatment within the institution can include the following services that are part of a patient treatment plan:
- Physical therapy programs typically used in POS 61 and consist of exercises, strength training, mobility work, and balance training.
- Occupational therapy, where patients are helped with ordinary daily tasks, such as dressing, bathing, and eating, as the person is being returned to independence.
- Speech and language therapy are critical for a patient recovering from a stroke, brain injury, or surgery affecting the patient’s ability to speak and/or swallow.
- Specialized nursing care around the clock will be available for the patient with recovery and medical management.
- Social work and case management services include coordination with patients and families to plan for discharge, arrange home care services, or link the family to a community resource.
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However, all services billed under POS 61 should be medically necessary and included in an approved plan of care. Accurate documentation will be critical to justify the use of POS 61 and support claims.
Where POS 61 is Used in Medical Billing
POS 61 is used specifically for rehabilitation facilities that are inpatient and have been accredited by Medicare and other insurers with very rigorous standards. Generally speaking, these are separate from general hospitals, although based hospital types may be.
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Admits from an inpatient facility to a POS 61 facility as a result of stabilization. For example, if a person has suffered from stroke, he may be transferred to POS 61 for more intensive rehabilitation prior to returning home. The scenario under which this category applies is when patients are medically stable but still require significant therapy before recovering their function and independence.
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POS 61 services are not applicable for outpatient rehabilitation. Also, it should not be confused with places of service codes for long-term care facilities and skilled nursing facilities. The medical billing system must be able to distinguish two different settings to ensure that the claims are not denied and are paid rightfully.
POS 61 Reimbursement in Medical Billing
Reimbursing services conducted under POS 61 has a different process as applied to many other health care environments. Medicare provides reimbursement to inpatient rehabilitation facilities pursuant to the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS). The emphasis under IRF PPS is on condition-based pricing rather than service-based pricing for a particular patient case.
To be reimbursed under POS 61, the facility must meet stringent conditions:
- The patient needs to have three hours of therapy at least five days of the week.
- There must be a multidisciplinary team providing care to the patient.
- Physician involvement in the treatment and regular revision of the treatment plan.
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Commercial insurance coverage for services provided under POS 61 may vary, although many insurance companies use standards similar to Medicare’s. Some require preservice authorization before the admission of a patient to any facility operating under POS 61. It is crucial for billers to be aware of all these conditions in order that claims may be accepted and paid promptly.
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Failure to use POS 61 properly may cause a delay or denial. For instance, if a claim under POS 61 is submitted while documentation does not substantiate the required intensity of rehab services, it will be denied.
Common POS 61 Medical Billing Errors
POS 61 needs to be applied correctly but there exist many common pitfalls likely to pronounce the life of claims:
- Using POS 61 for outpatient therapy – This is perhaps the most common billing error. POS 61 applies strictly to inpatient care; outpatient services should bill using different POS codes.
- Failure of documentation – In case the medical record does not sustain that the patient was subject to intensive therapy, the claim may be denied. All services must be documented accordingly.
- Use of POS 61 in unqualified facilities – Not all rehab facilities qualify for POS 61. The use of this code when the facility does not qualify may trigger audits or penalties.
- Absence of pre-authorization – Some insurers require pre-authorization prior to a patient’s admission to a facility billed under POS 61. Without such authorization, a claim may be denied.
- Incorrect DRG coding – The diagnosis-related group (DRG) codes must be in agreement with the patient’s condition and the treatment plan. Any inconsistencies with the use of POS 61 can bring red flags.
To avoid such errors, it is highly important that representatives from both the care team and billing team understand the requirements of POS 61 and why it is important. Ensuring communication through persistent discussion about this code, constant documentation, and continuous training can help halt potential issues.
Why POS 61 Matters in Medical Billing
Point-of-service code 61 is very important for purposes of medical billing because it signifies a very high level of care received in a specific type of facility. It indicates to payers that this patient required intensive inpatient rehabilitation as to how care was given.
The importance of getting POS 61 correct is not only for the sake of finances but also for patient care. Admission of a patient in a setting under such hospitality would focus on quality improvement and returning the patient to normal living. The patient would receive denial of the important attention for which these providers are paid.
Understanding POS 61 for a billing professional means that their organization will maintain standards to avoid expensive errors in denial and also smooth out claims processing. As healthcare keeps increasing its focus into recovery and post-acute care, the use of POS 61 will need to be even more critical.