Wiki In-Office Only Procedures

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dballard2004

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I have a denial for procedure 21011 for removal of a forehead mass performed in a plastic surgeon's office. The payer denied the claim stating this procedure can't be performed in the office setting. I am curious if there is some sort of designation on the MPFS showing what procedures can be performed in the office vs. those that can only be performed inpatient or ASC. I know designation of "C" is inpatient only, but anything to indicate office procedures? Thanks.
 
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I have been getting denials for lipoma excisions in office setting from United Healthcare, CPT code 21012 & 21931 so far. I have been searching the UHC portal for the policy on this but can't find anything. The UHC rep said the new policy became effective 4/1/23 and that they need to be billed with an assistant surgeon modifier. It is driving me crazy lol we have always performed these procedures in our Dermatology office.
 
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Bhignojos said:
I have been getting denials for lipoma excisions in office setting from United Healthcare, CPT code 21012 & 21931 so far. I have been searching the UHC portal for the policy on this but can't find anything. The UHC rep said the new policy became effective 4/1/23 and that they need to be billed with an assistant surgeon modifier. It is driving me crazy lol we have always performed these procedures in our Dermatology office.
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This particular payer is All Savers which is UHC as well. I found the policy on the UHC website about POS changes, but nothing that relates to code 21012. Is there anyone out there who can help? Thanks.
 
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Bhignojos said:
I have been getting denials for lipoma excisions in office setting from United Healthcare, CPT code 21012 & 21931 so far. I have been searching the UHC portal for the policy on this but can't find anything. The UHC rep said the new policy became effective 4/1/23 and that they need to be billed with an assistant surgeon modifier. It is driving me crazy lol we have always performed these procedures in our Dermatology office.
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I looked through the UHC policy updates I receive in my email, and I found an Outpatient Surgical Procedures - Site of Service policy effective 4/1/2023.

That policy has an appendix titled Outpatient Surgical Procedures - Site of Service: CPT/HCPCS Code List. That appendix lists 21011, 21012, 21013, and 21014.

I'm attaching the links to those policies, because it sounds perhaps like these documents could be what your UHC rep was referencing? (I'm just sharing the links to the source documents, not trying to interpret how UHC might be implementing the information.)

OP Surgery Site of Service effective 4/1/2023 https://www.uhcprovider.com/content...g/outpatient-surg-procedures-site-service.pdf

CPT/HCPC Appendix: https://www.uhcprovider.com/content...g-procedures-site-service-cpt-hcpcs-codes.pdf
 
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sls314 said:
I looked through the UHC policy updates I receive in my email, and I found an Outpatient Surgical Procedures - Site of Service policy effective 4/1/2023.

That policy has an appendix titled Outpatient Surgical Procedures - Site of Service: CPT/HCPCS Code List. That appendix lists 21011, 21012, 21013, and 21014.

I'm attaching the links to those policies, because it sounds perhaps like these documents could be what your UHC rep was referencing? (I'm just sharing the links to the source documents, not trying to interpret how UHC might be implementing the information.)

OP Surgery Site of Service effective 4/1/2023 https://www.uhcprovider.com/content...g/outpatient-surg-procedures-site-service.pdf

CPT/HCPC Appendix: https://www.uhcprovider.com/content...g-procedures-site-service-cpt-hcpcs-codes.pdf
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Thanks so much. This is exactly what I am looking for.
 
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