Wiki Medicare Denying for Overlapping Service

[klen]

Hi Coders,

My urologist submitted a claim that was initially paid, but they are now requesting a refund stating that our service was overlapping an inpatient hospital stay. We saw the patient in our office and had no indication that he was going to be admitted to the hospital. So, my question is...Is there a modifier that we can use on our claim to show that our service does not overlap the IP stay? We billed our claim with POS 11, but the Medicare representative told us to rebill with POS 21, which is completely incorrect since we saw the patient in office.

Any help would be greatly appreciated.

 

[Deborah Marsh]

Hi - Not sure if this Medicare rule applies to the specifics of your encounter, but Medicare Claims Processing Manual, Chapter 26, Section 10.5 (page 33 of https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26pdf.pdf), states:
"When a physician/practitioner furnishes services to a registered inpatient,
payment is made under the PFS at the facility rate. To that end, a
physician/practitioner/supplier furnishing services to a patient who is a
registered inpatient, shall, at a minimum, report the inpatient hospital POS code
21 irrespective of the setting where the patient actually receives the face-to-face
encounter. In other words, reporting the inpatient hospital POS code 21 is a
minimum requirement for purposes of triggering the facility payment under the
PFS when services are provided to a registered inpatient."

 

[klen]

Hi Deborah, thanks for your reply! I think this is exactly what I needed.