Wiki facility rvu's vs. non-facility rvu's

[djarrett]

I have recently had a claim denied by a Medicare PFFS because, they say, the place of service does not match service rendered. The code is 63650-spinal cord stimulator: trial and was billed with POS-11: office. When I asked what they meant, the explanation was that it had a facility RVU value assigned to it and therefore it could not be billed in an office setting. I explained to them that I have billed this procedure many, many times before to both Medicare and Commercial insurers in an office setting and have never had this come up. My question is, does the assignment of a facility RVU necessarily preclude payment in an office setting? I am left to wonder if this carrier is incorrectly interpreting this or are they using this to dodge payment. Thanks for any help or resources anyone can point me towards.

 

[ajs]

It would appear they don't know how to interpret the fee schedules! You can pull up the NCD on the CMS website under Regulations and Guidance, manuals, Internet Only Manuals then the NCD section and neuro stimulators is under section 160. I think you will find the ammunition you need to fight for payment.