Outpatient Facility Coding Alert

Question: I just got a recoup payment request from United Healthcare. The physician performed 25111 in the office setting. Place of service 11 is noted on the recoup letter. The reason for the recoup is that the payment of 25111 is linked with the place of service and POS 11 has been identified by CMS as a non-eligible service performed in non-facility setting. What should we do?

Florida Subscriber

Answer: This procedure safely and effectively performed in an ASC or other outpatient setting without compromising the quality of patient care. In a lower-level setting such as a physician’s office, prior authorization may be needed.

You should check with your insurer to verify that they cover minor ortho procedures in an office setting and whether you need prior authorization to bill POS 11 with 25111 (Excision of ganglion, wrist [dorsal or volar]; primary). Otherwise, coverage may be denied.

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