Wiki 25071 denied as inappropriate place of service

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JesseL

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I billed 25071 to fidelis and they are denying it as "inappropriate place of service"

I billed it as a in office procedure "11"

They say it's not appropriate per CMS guidelines? Is this true? Where do I find these guidelines because I googled around and found nothing.
 
OCD_coder said:
This procedure has a non-office based ASC status indicator of G2. This information is available on the CMS website.

https://www.encoderpro.com/epro/Help/WebHelp/EproStd/asc_indicators.htm

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1616CP.pdf

There are other status indicators that are applicable also.
http://health-information.advancewe...Status-Indicators-Bundling-and-Modifiers.aspx
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If thats the case, can I code it from the integumentary surgery section using the excision codes instead (CPT 11406)?

It was a lipoma that was excised and it was around 4cm..

They paid for the separate smaller lipoma, cpt 25075... I would have to code that along with 11406 and the repair 12032 for the larger one if that's allowed?
 
No you cannot substitute one code for another just for payment purposes, that is called intentional down coding. Your only choice is to write it off. You need to know those procedures that are not allowed in the office setting
 
mitchellde said:
No you cannot substitute one code for another just for payment purposes, that is called intentional down coding. Your only choice is to write it off. You need to know those procedures that are not allowed in the office setting
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Where do I find specifically that this code can't be coded in office?
I can't find anything on CMS that shows me a list of codes that can't be billed in office.
 
As OCD coder indicated it has a status indicator of G2 this means it is not allowed in the office setting. You need to query the CMS website for status indicators and their meanings.
 
mitchellde said:
As OCD coder indicated it has a status indicator of G2 this means it is not allowed in the office setting. You need to query the CMS website for status indicators and their meanings.
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How do I know that code has that status indicator?

I'm looking through CMS search function and it only comes up with what the status indicator means but doesn't tell me which cpt codes it applies to.
 
Actually.. I think I messed up the whole coding anyway.. They lipoma excision was full thickness not involving the subcutaneous layer. I thought full thickness included subcutaneous layer but it's "through the dermis"..

So I may have to submit a corrected claim anyway under the integumentary surgery section..
 
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My understanding is that status indicators are only used to indicate how a procedure will be paid if it is done in an ASC - but they don't mean that it has to be performed in an ASC. (As an analogy, if a diagnosis has a DRG, that does not mean that it can only be treated in a hospital.)

If you are performing procedures in the office only, you can ignore the entire concept of status indicators, as they have no relevance to your practice.

Fidelis may have rules (or a clause in your contract) requiring that certain procedures only be performed in ASCs or hospitals, and this may be why they denied it.
 
JesseL said:
Actually.. I think I messed up the whole coding anyway.. They lipoma excision was full thickness not involving the subcutaneous layer. I thought full thickness included subcutaneous layer but it's "through the dermis"..

So I may have to submit a corrected claim anyway under the integumentary surgery section..
Click to expand...

Full thickness is through the dermis and to or into the subq layer, but not through it, so yes it does include the subq layer. A lipoma excision should be coded in the 20000-29999 range.
 
I still don't know what to do with this, seems like a grey area. I still cant find evidenceanywhere that I cant bill 25071 as a in office procedure. Fidelis said something about CMS stating it's not billable but I don't see that anywhere.

The operative note says "carried through to the subcutaneous fat" so I don't think the provider cut through the subcutaneous layer but cut out part of it?

I'm finding that some people say not to use the the muscleskelatal section codes unless its excision through the subcutaneous layer.

Really don't know what to do with this.:confused:
 
Since the cut was only "to the sub-q," (not through it) this should be billed as an integumentary code.

Although it's no longer relevant to this claim, if the Fidelis rep said that CMS does not allow this to be billed in-office, my assumption is that she has no idea what she's talking about. (Would anyone on this forum be shocked to hear that an insurance rep gave you incorrect information.....?)
 
CatchTheWind said:
Since the cut was only "to the sub-q," (not through it) this should be billed as an integumentary code.

Although it's no longer relevant to this claim, if the Fidelis rep said that CMS does not allow this to be billed in-office, my assumption is that she has no idea what she's talking about. (Would anyone on this forum be shocked to hear that an insurance rep gave you incorrect information.....?)
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Well she read the denial off her computer that their claims department generated. They sent it out for review but I guess I gotta submit a corrected claim anyway since it seems I'm right to think that if the incision involved part of the subQ not through it, then I have to code it as an integumentary code.
 
I'm still trying to figure out how to find what procedures are not covered if done in office.

I've looked everywhere I can't find it anywhere.

Can someone point me in the right direction?
 
From a payment perspective, there are no limitations to what can be performed in-office except for those (if any) imposed by your insurance contracts.
 
CatchTheWind said:
From a payment perspective, there are no limitations to what can be performed in-office except for those (if any) imposed by your insurance contracts.
Click to expand...

They claimed they followed CMS guidelines but I see nothing on it. Not even on the LCD's when I searched for 25071. They don't even seem to have LCD's for that code:mad:
 
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