Wiki Pain Management OP Clinic

[vworsham]

a couple of my Anes Docs also run the Pain Mgt Clinic here at the hospital, place of service is 22. We have a PA who does Pain Pump Analyze, 62368 and Pump Refill, 95990. We keep getting a denial on 95990 not paid in place of service 22. Someone told us to try 96522 also a refill but we get the same denial.
Any help on this??

 

[marvelh]

Most of the injection, infusion, pump refill codes that can be reported by a non-physician provider carry the "5" PC / TC status indicator in the Medicare Physicain Fee schedule. This is defined as:

5 = Incident To Codes--This indicator identifies codes that describe services covered incident to a physician's service when they are provided by auxiliary personnel employed by the physician and working under his or her direct personal supervision. Payment may not be made by carriers for these services when they are provided to hospital inpatients or patients in a hospital outpatient department. Modifiers 26 and TC cannot be used with these codes.​

In essence, Medicare views these types of services in a facility site of service to be provided by the facilities' employees and not reimbursable to the physician.

For Medicare & those payers that strictly follow the Physician Fee schedule indicators, even if non-physician provider that is performing the procedure is a valid employee of / cost to the provider, no available options for "getting around this". Most also don't want to get on that "slippery slope" of reporting codes to circumvent a coverage policy just to get reimbursement.

 

[vworsham]

Thanks for the info. We had pretty much decided it was not worth the possible problems but wanted to try the forum in case anyone else had a similar situation. I really appreciate your time and info.