Wiki 96365 with POS 12

[rropp3230]

we have issue w/ BCBS as well. Our contract includes our per diem for home and office IV infusion. By contract, we can use 96365 or S9494. We were using the 96365 with a POS 12 and one claim for one patient denied.....so in working the claim, my billers were told we must use the S9494 for home infusion and now our claims are paying inconsistently. Can I use a POS 12 with a 96365?

 

[thomas7331]

I can't speak to your BCBS plan's rules or their policies on how to bill home infusions (and also without seeing your contract it's hard to give you a definitive answer on this), but under Medicare rules, 96365 is an 'incident to' code for use under the physician fee schedule, so this would normally only be used on a professional claim for services in the office. While it's theoretically possible that it could be billed with a POS 12, that would require the presence of the physician in order to meet the supervision requirements, so I would not consider it the correct code for billing a home health service which falls under a different category than a physician service. My guess is that BCBS would also consider this code an office service, and that is likely why they have assigned the S9494 code to you for use in the home setting and to distinguish it from an office service. But you're going to have to go to the source to know for sure - I'd recommend a review of the payer's policies and the contract, and if you aren't able to get clear guidance from those, then speak with your network representative to try to get clarification. I personally wouldn't rely on what the billers have been told by phone reps as they are notorious for giving out incorrect information.

 

[alderego002]

Hi,
We hardly use 96365. It's actually been a while. the Dr performed this in office with an Oral I&D. The claim was denied as included with service provided. Should I be using a modifier??