90966 POS 65 vs POS 12 – Is Molina Correct on Recoupments?

[Christig83]

Has anyone run into this?


We are billing 90966 (home dialysis MCP) with POS 65 when the monthly face-to-face ESRD MCP visit is performed in the dialysis clinic (patient is a home dialysis patient but comes in monthly).

Molina initially paid these claims and is now recouping them, stating POS 12 is required because the patient does home dialysis.

We cannot find CMS/AMA guidance requiring POS 12 for 90966 or stating the face-to-face must occur in the home.

Is anyone aware of:

• Any CMS rule tying 90966 to POS 12?
• Any guidance that POS must follow dialysis modality instead of where the encounter occurs?

Curious if this is a payer-specific interpretation or if we are missing something. Appreciate any references or payer policy insight.

 

[abranch13]

We had this happen with our local BCBS. They are using Carelon to audit claims and they were trying to recoup every 90966 w/POS 65 we billed in the past year. It took a few months of back and forth with BCBS, but they ended up stating these were in error and they should cover this CPT for either 65 or 12. There is no guidance that specifically states which POS should be used, if the payer is going to dictate it should be 12, then they should be putting that in their policies.