I have a claim that was originally paid by United Healthcare Medicaid. The services were performed in an office setting and the POS reported on the claim was 11. That money was then recouped. We enquired as to why it was recouped and were told by a rep from UHC that according to CMS, when a patient is a registered inpatient the physician services should be coded with a facility place of service code and the practitioner should be paid the facility rate irrespective of the setting where the patient actually receives the care. We were told the resubmit the claim with the correct facility place of service. This does not sound correct to me. We called Medicare to verify if this policy was correct but were told they couldn't help us as this was not a Medicare claim. Is there anyone who has ever encountered this and how did you solve it? Or where can we find this policy.
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Wiki POS for Inpatient
- Thread starter JLPruess
- Start date
eldinadedic
Networker
My providers see patients in the hospital and in the office. I never heard of that denial. It is not correct to bill POS 21 if pt was seen in office POS 11. I am sure that rep is misinformed. I would call and try to speak to another rep to see what answer you get. If they say the same then I would appeal. I was misinformed by UHC Medicaid many times. Please let me know if you ever resolved that issue.
Pam Warren
True Blue
If the patient was registered as an inpatient at a hospital or nursing facility, then they are not supposed to receive services in a location other than that specific admission. This sometimes happens when a patient is in a nursing home rehab stay and gets a ride from a family member to the doctor's office or wound clinic. The rehab (or hospital) is supposed to provide the patient with all care during that stay (that's part of their payment), or the provider sees the patient at the facility. The patient is not supposed to leave the hospital/rehab to go to an outpatient service. Are you sure that when the patient was seen in the office, they weren't also within a hospital or rehab stay? I'm betting that this is what happened.