# Place of Service- URGENT HELP NEEDED



## Hbowles75 (Mar 24, 2009)

My company is a Home Care Physician Group (WE ARE NOT A HOME HEALTH AGENCY WE ARE A PHYSICIAN GROUP) based out of Desoto; about 96% of all of our patients are seen by our Physicians and NP's in their homes. Recently we decided to expand our practice to include pulmonary diagnostic testing. We have purchased state of the art portable testing equipment and have hired and certified technicians to go out to the patient's home and perform these tests.

We currently use the following codes: 94010: "Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement, with or without maximal voluntary ventilation."
 or 94060:" Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration."
 in conjunction with 94620: "Pulmonary stress testing; simple (eg, 6 min walk test, prolonged exercise test for bronchospasms with pre- and post-spirometry and oximetry"

Since both of these tests are performed in the home of the patient and not in the office we billed Medicare with the Place of Service 12.
Medicare paid the 94620 code in that place of service but denied back the 94010 and 94060 (not billed together but either or) stating that that code was not payable in that place of service. I appealed the decision and was answered back that Medicare was advised that these tests could not accurately be done in the patients home so they chose not to add that place of service to the list. 

My company CFO (who is also in charge of setting up the Pulmonary
Department) spoke with several people in the Pulmonary Field who advised him that they had been having this issue with Medicare for the past 10 years and that EVERYONE bills these tests with Place of Service 11 (in
office) to get Medicare to pay them. They also told him that Medicare knew of this practice and it was accepted as it was done as a "Peer Group".

At the same time we also filed a Medicare Enrollment App to open an IDTF (since this is completely acceptable to bill these codes under for full
payment) 

I contacted Medicare Provider Relations Department and asked them to advise me on changing the Place of Service Code from 12 to 11 as advised by the "peer group" I spoke with Sharice who said that if we were billing for Physician Interpretation that we could bill the claims with Place of Service 11 instead of 12. I told her that we were not billing the interpretation but the actual testing she took the codes and placed me on hold. When she returned she told me that those two codes were testing codes and that they had to be billed in the place of service that the testing was done in. So we are back to POS 12.

I then contacted the Medicare Provider Enrollment Department and asked them if our company would qualify as an IDTF, Mike assured me that we would and gave me the name and number of the state department contact. I contacted her and she confirmed that we would qualify as an IDTF and as long as we met the requirements there should be no issues.

Meanwhile back at the office the CFO is still advising me to adjust my claims and bill them all out to Place of Service 11 so that we can get them paid per his conversation with the pulmonary "peer group." I have advised the owner of the group that I believe that this constitutes Medicare Fraud and have advised against changing the place of service just to get the claims paid and waiting on the IDTF to come in. The owner says that he wants an outside expert opinion to settle the issue.

So my question is this: if we do the testing in the home on the codes 94010 and 94060; can we change the Place of Service code to 11 to reflect in the office to get payments based on the advisement of a peer group?



Thank you so very much for your time and consideration on this matter.
Any help would be appreciated!


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## sdeaton (Mar 24, 2009)

A medical claim must reflect an "accurate" picture or representation of the services rendered, including where they were performed.  Coding in a manner simply "to get a claim paid" constitutes fraud.


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## LLovett (Mar 24, 2009)

*I agree it is fraud....*

Place of service errors are on the OIG 2009 work plan. They don't specifically state your situation but the intent is basically the same.

http://oig.hhs.gov/publications/docs/workplan/2009/WorkPlanFY2009.pdf

page 31 in the adobe reader version


Good luck,

Laura, CPC


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## LOVE2CODE (Mar 24, 2009)

*I agree*



sgarrett said:


> A medical claim must reflect an "accurate" picture or representation of the services rendered, including where they were performed.  Coding in a manner simply "to get a claim paid" constitutes fraud.



Very well said.....


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## debksmith1 (Mar 24, 2009)

*Colonoscopic Manipulation of Gravida Uterus*

I have been searching the CPT book for anything that comes close and really didn't find anything.  It sounds like this is an accepted procedure, but rarely comes up so I'm not sure what to use?  Anyone that can help with suggestions I'd appreciate it.  This is done generally in the hospital under anesthesia when the uterus is malpositioned during pregnancy.


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## lnaschke (Mar 25, 2009)

*who is your medicare carrier*

you can follow the following steps to appeal you carrier's decision.  If is very cumbersome and time consuming, but if the dollar amount is large enough, it might be worth it.  I copied this from the Trailblazer Health website, which is the Mac for Texas.

Once an initial claim determination is made, Medicare offers providers and beneficiaries the right to appeal Medicare coverage and payment decisions. Medicare offers five levels in the Part A and Part B appeals process. The levels listed in order are:
Redetermination – A redetermination is an examination of the initial claim decision. A request for a redetermination must be submitted in writing within 120 days of receipt of the initial claim determination. 
Reconsideration – A reconsideration is the second level of appeal for providers and beneficiaries who are dissatisfied with their redetermination, and is performed by a Qualified Independent Contractor (QIC). A request for a reconsideration must be filed within 180 days of receiving the TrailBlazer first level of appeal or “redetermination” decision. 
Administrative Law Judge (ALJ) Hearing – If at least $120 remains in controversy following the QIC's decision, a reconsideration through an ALJ hearing may be requested within 60 days of receipt of the reconsideration decision. 
Medicare Appeals Council (MAC) Review – If dissatisfied with an ALJ decision, a review by the MAC may be requested. Requests must be submitted in writing within 60 days of receipt of the ALJ's decision. 
Judicial Review in U.S. District Court – If $1,220 or more is still in controversy after a MAC's decision, judicial review by a federal District Court judge may be requested within 60 days of receipt of the MAC's decision. 

Hope this helps
Laura


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