Wiki Resources for POS restrictions?

[sinman0531]

I have a provider who performed a 21932 in office, and the claim is denying for inappropriate place of service. I'm sure this is correct, but I just cannot find any specific resource that says you can't perform this procedure in an office setting. If we want to write it off, we have to have reliable proof.

Thank you!

 

[sls314]

I have a provider who performed a 21932 in office, and the claim is denying for inappropriate place of service. I'm sure this is correct, but I just cannot find any specific resource that says you can't perform this procedure in an office setting. If we want to write it off, we have to have reliable proof.

Thank you!

Before writing off the charge, I'd confirm whether the correct CPT code was used.

This CPT code indicates that a tumor is excised from the deep soft tissue, below the fascial plane or within the muscle. It would be done under anesthesia and allows an assistant surgeon.

Does the documentation support the excision of an intramuscular tumor? Or is there a more accurate excision CPT code that would be used?

To answer your question about office-based procedures, though, CMS classifies 21932 as a non-office-based surgical procedure.

(That distinction means that when performed in an ASC, it will be paid at OPPS rates. When a surgical procedure commonly performed in provider offices gets done in an ASC, the payment is capped at the MPFS rates. That payment provision theoretically keeps procedures from being shifted from the office to the ASC. Status indicator G2 means a procedure isn't commonly done in the office so that the ASC will be reimbursed at OPPS rates. You could look at the G2 indicator for a general idea of what CMS thinks isn't commonly done in the office - just remember the purpose of the indicator is for ASC reimbursement. It shouldn't be taken as an absolute list to be followed by a physician's office.)

Your best bet is to see whether the documentation actually supports CPT 21932.

 

[sls314]

Much of it will be payer dependent also. For example, UHC has an Outpatient Surgical Procedures - Site of Service Policy effective 7/1/2023.

The policy isn't specifically about physician's offices. It pertains more to when a procedure can be done in an outpatient hospital setting vs. an ASC. However, you'll note that CPT 21932 is on the list.

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/outpatient-surg-procedures-site-service.pdf

 

[sinman0531]

Before writing off the charge, I'd confirm whether the correct CPT code was used.

This CPT code indicates that a tumor is excised from the deep soft tissue, below the fascial plane or within the muscle. It would be done under anesthesia and allows an assistant surgeon.

Does the documentation support the excision of an intramuscular tumor? Or is there a more accurate excision CPT code that would be used?

To answer your question about office-based procedures, though, CMS classifies 21932 as a non-office-based surgical procedure.

(That distinction means that when performed in an ASC, it will be paid at OPPS rates. When a surgical procedure commonly performed in provider offices gets done in an ASC, the payment is capped at the MPFS rates. That payment provision theoretically keeps procedures from being shifted from the office to the ASC. Status indicator G2 means a procedure isn't commonly done in the office so that the ASC will be reimbursed at OPPS rates. You could look at the G2 indicator for a general idea of what CMS thinks isn't commonly done in the office - just remember the purpose of the indicator is for ASC reimbursement. It shouldn't be taken as an absolute list to be followed by a physician's office.)

Your best bet is to see whether the documentation actually supports CPT 21932.

The note does clearly identify that there was a 2x3cm lipoma/tumor found intramuscularly. We also perform MOHs, so we do have the ability to do more complex procedures in a dedicated surgical suite, but the suite does not have its own designation, its still considered part of the office.

This is a doctor who regularly performs procedures he shouldn't (such as debriding bone in the office) so....we are not confident we can get it paid. But I will forward it over to our supervisor to see what she wants to do. Thank you!

 

[jkyles]

I have a provider who performed a 21932 in office, and the claim is denying for inappropriate place of service. I'm sure this is correct, but I just cannot find any specific resource that says you can't perform this procedure in an office setting. If we want to write it off, we have to have reliable proof.

Thank you!

Hi there, Medicare's physician fee schedule lists the non-facility indicator for that code as NA (not applicable).

www.cms.gov/medicare/physician-fee-schedule/search?Y=0&T=4&HT=0&CT=0&H1=21932&M=5

An “NA” in this field indicates that this procedure is rarely or never performed in the non-facility setting.

www.cms.gov/medicare/medicare-fee-service-payment/physicianfeesched/pfs-relative-value-files/rvu23b