Wiki treatment deemed by the payer to have been rendered in an inappropriate place of service

[LISAGASHO]

Hello,
I have a provider listing I20.0 (unstable angina) with POS 11. Claim is denying for "treatment deemed by payer to have been rendered in an inappropriate place of service". ICD-10 does associate symbol CC (comorbidity or complication-inpatient only) and IOCE (integrated OCE edit). ICD-10 description states this is considered a medical emergency which requires acute care hospitalization.

Provider saw patient for heartburn, did EKG with abnormal results. Recommendation was to use heartburn and abnormal EKG. Provider is pushing back that unstable angina is the appropriate condition to bill out. I have let provider know claim is denying, but provider still pushing back. Provider did send patient to hospital, they were admitted and had bypass surgery.

Does anyone have a resource or info on this type of edit. I have been looking on CMS and some other resources but can't seem to find info related to this particular issue.

Thanks,

Lisa Gasho

 

[csperoni]

I have never heard of a denial for inappropriate place of service linked to the diagnosis. I have only ever seen that based on the procedure (CPT). A patient could present to your office for all sorts of things that would actually require ER or hospitalization, but they did present to you first. I would clarify with the payor if the denial is related to the ICD10.

 

[shanamarie]

Hello,
I have a provider listing I20.0 (unstable angina) with POS 11. Claim is denying for "treatment deemed by payer to have been rendered in an inappropriate place of service". ICD-10 does associate symbol CC (comorbidity or complication-inpatient only) and IOCE (integrated OCE edit). ICD-10 description states this is considered a medical emergency which requires acute care hospitalization.

Provider saw patient for heartburn, did EKG with abnormal results. Recommendation was to use heartburn and abnormal EKG. Provider is pushing back that unstable angina is the appropriate condition to bill out. I have let provider know claim is denying, but provider still pushing back. Provider did send patient to hospital, they were admitted and had bypass surgery.

Does anyone have a resource or info on this type of edit. I have been looking on CMS and some other resources but can't seem to find info related to this particular issue.

Thanks,

Lisa Gasho

What payor is it? Ucare just implemented something a few months ago that rejects claims with certain ICD 10 codes listed, and it rejects saying inappropriate dx used for POS. Meaning they would never expect claims with certain codes in an outpatient setting. Like I63.9 cerebral infarct, if we have a claim with this code and we believe it’s appropriate to use in an outpatient setting, we have to send the records and claim to insurance via our payor rep to even get them to look at it. Thankfully we don’t have many of these, but we are an imaging center so sometime things are found on scans that are appropriate to code even in an outpatient setting.

 

[iowagirl77]

Hello,
I have a provider listing I20.0 (unstable angina) with POS 11. Claim is denying for "treatment deemed by payer to have been rendered in an inappropriate place of service". ICD-10 does associate symbol CC (comorbidity or complication-inpatient only) and IOCE (integrated OCE edit). ICD-10 description states this is considered a medical emergency which requires acute care hospitalization.

Provider saw patient for heartburn, did EKG with abnormal results. Recommendation was to use heartburn and abnormal EKG. Provider is pushing back that unstable angina is the appropriate condition to bill out. I have let provider know claim is denying, but provider still pushing back. Provider did send patient to hospital, they were admitted and had bypass surgery.

Does anyone have a resource or info on this type of edit. I have been looking on CMS and some other resources but can't seem to find info related to this particular issue.

Thanks,

Lisa Gasho

What CPTs were billed? I agree with csperoni- it is not as likely that the diagnosis is causing the issue. I believe it is more likely the CPT with that POS combination. One other thought, if the patient was admitted to the hospital that same day there could be something that is conflicting there, such as if they see EKG performed at both places and the payor is confused with similar charges but different POS.