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poyersaug 03-19-2013 10:09 AM

Can anyone tell me why 19295 is not being paid from Medicare, stating it was rendered in an inappropriate or invalid place of service

sbutler0023 05-02-2013 07:41 AM

I would also like to know or find some information on this. Thanks!

mitchellde 05-02-2013 08:01 AM

Well, hard to tell with limited info, what other code did you bill this with, since 19295 is an add on code, and what POS did you use and where was the procedure performed and what diagnosis did you use.

JREDLINE 05-02-2013 08:14 AM

Long story short: It is now listed as technical-component only. Here is the long story:

This is from the RBMA listserve, ACR's Diane Hayak, Director, Economics & Health Policy posted the following information:
In the 2012 Relative Value Scale Update Committee (RUC) database, the practice expense relative value units (RVUs) for code 19295 were 2.65 for facility (hospital) and non-facility (nonhospital) and priced at a national average of $90.38. This was to cover the cost of the clip and any indirect overhead value associated with the placement of the clip. As of January 1, 2013, the RVUs were removed from the Medicare Physician Fee Schedule (MPFS) for the facility setting. That means that the Centers for Medicare and Medicaid Services (CMS) assume that physicians are not supplying the titanium clips for the hospital and should not be reimbursed for them. When the hospital purchases the clip, the hospital is paid separately under the Hospital Outpatient Prospective Payment System at a rate of $49.64 or as part of the cost of the breast biopsy. As the hospital is not reimbursed under the MPFS, NA [not applicable] is now listed under the column titled facility (hospital).

According to the 2013 CPT® and RUC database, CPT code 19295 Image-guided placement, metallic localization clip, percutaneous, during breast biopsy (List separately in addition to code for primary procedure) was created to describe the placement of a metallic clip during a breast biopsy. CPT code 19295reported in addition to the code for breast biopsy. There are no work relative value recommendations, as the RUC agreed the work for placement of the clip marker code is included in the work of the parent code. The RUC agreed that there is minimal additional work and recommends a 0.00 work RVU for code 19295.

Physician work associated with the placement of the clip is considered included in the payment paid under the base procedure code 10022, 19102 or 19103. However, the physician is reimbursed for the cost of the clip when he/she purchases the clip, the procedure is performed in the non-hospital setting, and the procedure is reported with code 19295. Regardless of who gets reimbursed for the clip and regardless of any payment policy, the physician who placed the clip should continue to report 19295.

Look for new bundled codes to describe breast biopsy procedures and placement of the clip to be available in 2014. The breast biopsy with guidance codes were identified in the 75 percent screen for code pairs with apparent duplication of physician work. The codes identified with apparent duplication of physician work were 77031, 77032, 76098, 19103, 19290 and 19295. The CPT®/RUC Workgroup, now known as the relativity assessment workgroup or RAW, requested that a bundled coding solution be pursued by the specialty societies.

See the March/April ACR Radiology Coding Source, due to be posted the end of April, for a detailed listing of CPT code changes expected in 2014.

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