Kristimiller0623
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- Messages
- 3
- Location
- Columbus, GA
Patient's currently in SNF are following up with our providers after total joint replacements. We are billing the SNF the TC component of the x-ray and Medicare the professional component - 26. Medicare is denying the billing of modifier 26 indicating the patient is in a SNF. We have always billed the modifier 26 component with place of service 11. Medicare is advising to bill with place 31. Any insight?
Palmetto GBA Chat
Transcript for 10/20/2026
Shamica has joined the chat. Your Chat
SHAMICA (11:47:22 AM)
Welcome to Medicare secure
chat, how may I assist you today?
Please hold for a minute or two
while I find that information for you.
Hi Shamica, yes ma'am thank you
SHAMICA (11:54:43 AM)
Your claim is denying for invalid place of service
on your claim for the procedure code. Our records
show that the patient was inpatient from 04/03/2026
thru 04/20/2026 and the facility NPI
I'm sorry I didn't realize you were looking for
the claim denial.. I selected to check appeal
status. We submitted an appeal on 8/17/2026
Correction 8/07/2026
SHAMICA (11:57:10 AM)
The appeal has been affirmed and the denial has been upheld.
10/20/26, 12:38 PM Palmetto GBA Chat Transcript
https://onlineproviderservices.com/ecx_improvev2/getMcsClaimDetails.do# 1/5
Could I get a copy of that? I do not see it in the portal
under that claim. or maybe direct me where to find it?
SHAMICA (12:01:01 PM)
The appeal letter was sent out on 10/15/2026 advising you that
the appeal has been affirmed and the denial has been upheld.
We do not show it, could you advise me
where to find it or send it to me, please?
SHAMICA (12:04:19 PM)
The letter was sent out on 10/15/2026 and it will take
up to 7 to 10 days for the letter to b received through
the mail. If you have not received this letter after 7
to 10 days please reach back out so the letter can
be resent to the correspondence address on file.
Ok thanks, so can it not be found on the website?
SHAMICA (12:06:37 PM)
If your provider is enrolled in green mail you should see
the letter in the eservice portal but if the provider is not
enrolled you will not see the letters in the eservice portal.
Ohh I see. Ok I will check with my manager on
that. So could you please elaborate on this appeal
being upheld.. We usually get paid with using
the 26 modifier and now we are getting denials.
Regional rehab paid the technical component
claim we billed to them and we are supposed to
10/20/26, 12:38 PM Palmetto GBA Chat Transcript
https://onlineproviderservices.com/ecx_improvev2/getMcsClaimDetails.do# 2/5
get paid for the professional claim from medicare.
SHAMICA (12:12:39 PM)
The patient was in a inpatient for this date of
service so you would need to resubmit your claim
with a valid place of service as the patient would
not in the office and the hospital at the same time.
but the pos is correct because it was done in office at our clinic
The rules are showing we billed correctly
The rehab brought the patient to our clinic
If you disagree with the decision of the appeal you have 180
from the denial date of the 1st level appeal to submit a 2nd
level appeal as Medicare has determined this will not be paid.
Your second level appeal will need to
be submitted to the QIC for processing.
Thanks, this just doesn't make any sense.
We will submit a second level appeal
SHAMICA (12:18:59 PM)
You're welcome.
It was a pleasure assisting you today, is there
anything else that I could help you locate?
Could you tell me what was used to determine the
appeal being upheld? like in the MCD on cms.gov?
SHAMICA (12:24:21 PM)
E planation of the decision The Medicare
10/20/26, 12:38 PM Palmetto GBA Chat Transcript
https://onlineproviderservices.com/ecx_improvev2/getMcsClaimDetails.do# 3/5
Explanation of the decision: The Medicare
physician fee schedule includes two payment
amounts depending on if a service is
performed in a facility setting, such as an outpatient hospital
department, or ambulatory surgical
center, or in a non-facility setting. The payments to physicians
are higher when the services are
performed in non-facility settings. The higher payments are
designed to compensate physicians
for the additional costs incurred to provide the service at an
office location opposed to a facility
location. Physicians are required to identify the place of service
on the health insurance claims
they submit to Medicare contractors. The correct place of
service code ensures that Medicare
does not reimburse a physician incorrectly for the overhead
portion of the payment if the service
was performed in a facility setting.
The claim submitted to Medicare indicated the place of service
as an outpatient or office setting.
According to our records, the beneficiary was an inpatient in a
covered Part Astay on the
appealed date of service. Therefore, the claim remains denied.
If the beneficiary was not in an
inpatient stay at the time of the service, the facility will have to
file a corrected claim to Medicare
Part A.
This decision is based on the Centers for Medicare &Medicaid
Services (CMS) Internet-Only
Manual (IOM), Publication 100-04, Chapter 12, Section 20.4.2.
This policy provides the
coverage criteria that determine whether payment for a service
can be made. The IOM can be
found at www.cms.gov.
Thank you for chatting with us today! Please come back if you
need any assistance in the future. We will be happy to hel
Palmetto GBA Chat
Transcript for 10/20/2026
Shamica has joined the chat. Your Chat
SHAMICA (11:47:22 AM)
Welcome to Medicare secure
chat, how may I assist you today?
Please hold for a minute or two
while I find that information for you.
Hi Shamica, yes ma'am thank you
SHAMICA (11:54:43 AM)
Your claim is denying for invalid place of service
on your claim for the procedure code. Our records
show that the patient was inpatient from 04/03/2026
thru 04/20/2026 and the facility NPI
I'm sorry I didn't realize you were looking for
the claim denial.. I selected to check appeal
status. We submitted an appeal on 8/17/2026
Correction 8/07/2026
SHAMICA (11:57:10 AM)
The appeal has been affirmed and the denial has been upheld.
10/20/26, 12:38 PM Palmetto GBA Chat Transcript
https://onlineproviderservices.com/ecx_improvev2/getMcsClaimDetails.do# 1/5
Could I get a copy of that? I do not see it in the portal
under that claim. or maybe direct me where to find it?
SHAMICA (12:01:01 PM)
The appeal letter was sent out on 10/15/2026 advising you that
the appeal has been affirmed and the denial has been upheld.
We do not show it, could you advise me
where to find it or send it to me, please?
SHAMICA (12:04:19 PM)
The letter was sent out on 10/15/2026 and it will take
up to 7 to 10 days for the letter to b received through
the mail. If you have not received this letter after 7
to 10 days please reach back out so the letter can
be resent to the correspondence address on file.
Ok thanks, so can it not be found on the website?
SHAMICA (12:06:37 PM)
If your provider is enrolled in green mail you should see
the letter in the eservice portal but if the provider is not
enrolled you will not see the letters in the eservice portal.
Ohh I see. Ok I will check with my manager on
that. So could you please elaborate on this appeal
being upheld.. We usually get paid with using
the 26 modifier and now we are getting denials.
Regional rehab paid the technical component
claim we billed to them and we are supposed to
10/20/26, 12:38 PM Palmetto GBA Chat Transcript
https://onlineproviderservices.com/ecx_improvev2/getMcsClaimDetails.do# 2/5
get paid for the professional claim from medicare.
SHAMICA (12:12:39 PM)
The patient was in a inpatient for this date of
service so you would need to resubmit your claim
with a valid place of service as the patient would
not in the office and the hospital at the same time.
but the pos is correct because it was done in office at our clinic
The rules are showing we billed correctly
The rehab brought the patient to our clinic
If you disagree with the decision of the appeal you have 180
from the denial date of the 1st level appeal to submit a 2nd
level appeal as Medicare has determined this will not be paid.
Your second level appeal will need to
be submitted to the QIC for processing.
Thanks, this just doesn't make any sense.
We will submit a second level appeal
SHAMICA (12:18:59 PM)
You're welcome.
It was a pleasure assisting you today, is there
anything else that I could help you locate?
Could you tell me what was used to determine the
appeal being upheld? like in the MCD on cms.gov?
SHAMICA (12:24:21 PM)
E planation of the decision The Medicare
10/20/26, 12:38 PM Palmetto GBA Chat Transcript
https://onlineproviderservices.com/ecx_improvev2/getMcsClaimDetails.do# 3/5
Explanation of the decision: The Medicare
physician fee schedule includes two payment
amounts depending on if a service is
performed in a facility setting, such as an outpatient hospital
department, or ambulatory surgical
center, or in a non-facility setting. The payments to physicians
are higher when the services are
performed in non-facility settings. The higher payments are
designed to compensate physicians
for the additional costs incurred to provide the service at an
office location opposed to a facility
location. Physicians are required to identify the place of service
on the health insurance claims
they submit to Medicare contractors. The correct place of
service code ensures that Medicare
does not reimburse a physician incorrectly for the overhead
portion of the payment if the service
was performed in a facility setting.
The claim submitted to Medicare indicated the place of service
as an outpatient or office setting.
According to our records, the beneficiary was an inpatient in a
covered Part Astay on the
appealed date of service. Therefore, the claim remains denied.
If the beneficiary was not in an
inpatient stay at the time of the service, the facility will have to
file a corrected claim to Medicare
Part A.
This decision is based on the Centers for Medicare &Medicaid
Services (CMS) Internet-Only
Manual (IOM), Publication 100-04, Chapter 12, Section 20.4.2.
This policy provides the
coverage criteria that determine whether payment for a service
can be made. The IOM can be
found at www.cms.gov.
Thank you for chatting with us today! Please come back if you
need any assistance in the future. We will be happy to hel