surgery denied for invalid place of service

trarut

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This question is geared to physician billing. We recently received a denial for a radical hysterectomy citing an invalid place of service. We billed it as outpatient and have confirmed this with the hospital where the surgery was performed. One of my coders was told by a rep at one of the local hospitals that they've suddenly had many denials for the same reason and I had a call from a peer at another practice with the same problem, also on a radical surgery claim. The payers denying are Medicare and Medicaid plans. We've been reviewing past updates from the payers to see if we missed a POS change but can't find anything.

So my question: is anyone else experiencing unexpected denials like this, where the POS is correct, or have you heard of any major POS changes that went into effect in the last 2-3 months? I'm wondering if there was a change on the facility side that's being applied inappropriately or having a trickle down impact on the physician side.

Thanks in advance,
Tracy
 

CodingKing

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58548 has an APC Status indicator of C meaning its on the inpatient only list. They will not pay for outpatient setting if it has this status. I'm not sure why its newly happening because its been on the list since at least 2015

Several other TAH codes are also on the list.
 
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trarut

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Coding King, being on the physician side, we typically aren't affected by the APC status, at least in my experience. Even more interesting is that the hospital is seeing denials it hasn't seen before for the same types of services. However, I can see where we would be denied if the hospital is denied. I'll do some digging into this. Thanks for the lead, all info helps at this point!
 

CodingKing

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It does seem odd that the hospital would not have been affected by it until now, Its not really a new concept to facilities. Ive gone back as 2009 so this procedure has been on that list for years.

I did see at one point it didn't affect physician offices only facility charges so maybe that is just new?
 
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