Pessary billing

[PaolaR]

Anyone having trouble getting paid for pessaries when billed with POS 11?
I have an insurance company telling me that we need to bill CPT code A4561 with POS 12 as the patient is using the pessary at home. But we insert them in the office.

 

[danskangel313]

Anyone having trouble getting paid for pessaries when billed with POS 11?
I have an insurance company telling me that we need to bill CPT code A4561 with POS 12 as the patient is using the pessary at home. But we insert them in the office.

It's likely that the payer is interpreting this as a supply being dispensed by a provider, which will ultimately be used at home. The fitting and insertion is done in the office, but the device is not being used there. I'm not saying this is the proper way to bill, but it seems as though they want you to charge the fitting and insertion with POS 11 and separately charge the supply code with POS 12. I don't quite understand why this would be the case, but...

 

[PaolaR]

That is exactly what they want. My office is worried about billing it that way. They are afraid of being accused of fraud or having the insurance company comeback for the money. Does anyone have any idea of where can I find the medicare billing regulations for this?

 

[danskangel313]

I would also feel hesitant about billing on 2 separate claims. Personally I would ask the payer to provide you with documentation that shows that's their policy and prove that it's an acceptable way to bill. If they have nothing legitimate in writing, I would appeal based on the fact they are asking you to bill improperly. If the payer is telling to you disregard standard billing practices in order to get payment, they need to be called out on it.

 

[PaolaR]

Thank you! You have been very helpful.