Wiki MPFS for 22902 - Facility or Non-facility?

[cfwh671]

I'm negotiating a new fee schedule for CPT 22902 with a private insurance. It will be done at the hospital because the physician's clinic is not equipped to perform this procedure. Am I supposed to negotiate based on the MPFS facility rate or the non-facility rate? The insurance company is telling me 22902 should be non-facility regardless of location. Are they right?

 

[thomas7331]

Under Medicare reimbursement rules, there is a site of service differential for this code - the office reimbursement is significantly higher, as would be expected since the physician is bearing all of the technical costs of the procedure - supplies, staff time, etc. But not all commercial insurance companies follow Medicare's reimbursement system and may or may not recognize the site of service differentials on the same codes.

I've heard some discussion among payers about these soft tissue tumor codes such as the one you're negotiating, and I think there's a growing opinion that these codes should be reserved for procedures performed in a facility. I don't necessarily agree with this, but I do think there's been abuse of these codes by some providers who may bill them for procedures that would have been more appropriately billed with the skin & subcutaneous excision codes instead, so it wouldn't surprise me if a commercial payer made a policy decision not recognize these codes for office use.