Wiki Pump refill denial

[Walker22]

I have a Medicare denial for a pump refill that I am trying to get paid. We order a custom compounded drug for this patient. On the day that the patient was due to come to our office for the refill, she was admitted to the hospital for an unrelated condition. My physician took the meds to the hospital and refilled the pump there. We billed 95991, 62368, and J3490 in place of service 21 (inpatient hospital). Medicare paid the programming code (62368), but denied the other 2 codes as "invalid place of service".

Does anyone know how I would go about appealing this? I can't find anything on the CMS website to address this situation. Thanks for your help!

 

[marvelh]

The code 95991 should have processed through if the physician himself did the refill as indicated by the code. CPT code 95990 carries a "5" PT/TC indicator or "incident to service" that means MCR will not process for payment when performed in a facility site of service.

But that is not the case for 95991 which carries a "0" or physician service PT/TC indicator & also has allowances for facility site of service. I would appeal that one. It is somewhat unusual for the physician to perform in an inpatient setting but as you indicated in this instance was performed.

As for the drugs, you won't have much luck as MCR considers all medications to be inclusive to the inpatient stay. In the perfect world [:>)], your physician should have ordered the compounded pump refill med from the hospital pharmacy and then filled the pump. However, in reality, most don't think about non-coverage for drugs or the technical component of all diagnostic studies. You can approach the hospital pharmacy to see if they would perhaps cover the cost of the invoice of the compound. But when this is addressed after the fact, I have not had great luck in convincing them that they need to reimburse the physician due to the MCR inclusion of all medications for inpatients. It's worth a try but probably not good odds of getting it covered.

I have had a physician learn a "hard" lesson with taking botulinum toxin to a hospital to inject it in a inpatient as the pharmacy didn't have it stock on that particular morning. The doc went to her office & brought the botulinum toxin to the hospital & injected the patient. MCR refused to pay due to the facility site of service & the hospital essentially said "to bad, so sad" as they could have gotten it in later that day! A costly lesson but she won't ever do that again!

Good luck!

 

[Walker22]

Thank You!