Wiki Trial SCS & facility rvu's vs non-facility rvu's

[djarrett]

I posted this on the general board, but I thought I'd better post it here as well:
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I have recently had a claim denied by a Medicare PFFS because, they say, the place of service does not match service rendered. The code is 63650-spinal cord stimulator-trial and was billed with POS-11, office. When I asked what they meant, the explanation was that it had a facility RVU value assigned to it and therefore it could not be billed in an office setting. I explained to them that I have billed this procedure many, many times before to both Medicare and Commercial insurers in an office setting and have never had this come up. My question is, does the assignment of a facility RVU necessarily preclude payment in an office setting? I am left to wonder if this carrier is incorrectly interpreting this or are they using this to dodge payment. Thanks for any help or resources anyone can point me towards.

 

[nrichard]

http://www.cms.gov/apps/physician-f...h-results.aspx?Y=0&T=4&HT=0&CT=3&H1=63650&M=5
Above is a link to CMS physician fee schedule for this CPT code. It only lists RVUs for the facility, and NA in Non-Facility which is my understanding they will not pay it in place of service 11. If you've not had problems in the past, it may be due to payer specifiic guidelines.

 

[dwaldman]

L8680 Implantable neurostimulator electrode, each

Did you also bill the above code and what was their response?

Another thing to do is obtain the other patients with the same carrier call back and say you previously responded that this was not paid because of the POS, please look at these other examples where payment was made. What makes this claim different. Also I would call the tech from the device company that is supplying the leads and state you need to talk to the reimbursement manager from their company for your region. They might be aware of other providers having the same issue and have more information.

 

[djarrett]

Thanks for the help. I'm going to go thru their formal reconsideration process. It's interesting that the payer states 'we follow Medicare guidelines' but Medicare pays for this when done in office! I don't know how they'll respond to that. Also, they paid for the leads (L8680) but not the trial stim (63650). I will contact the device rep, too. That's a good idea.