Health Information Management

Q&A: Report proper point of service code with CPT code 37201

JustCoding News: Outpatient, September 23, 2009

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QUESTION: Does Medicare pay for CPT code 37201 (Transcatheter therapy, infusion for thrombolysis other than coronary) when the provider performs this procedure in the office setting (place of service [POS] code 11? We are a Medicare Advantage health plan, and one of our providers (a physician) bills for this procedure using POS code 11, but we denied his or her claim, stating the POS is inappropriate for the procedure.

The Medicare Physician Fee Schedule indicates that providers rarely perform this procedure in a non-facility setting. However, the physician indicated that Medicare reimburses for this procedure when performed in the office. We requested medical records, and we think that the physician performed the procedure in his or her dialysis center. So we believe the provider should have reported another POS code. Do you have any information about this procedure code?

ANSWER: The complete description for POS code 11 indicates the following:

A location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

POS code 65 indicates a facility, other than a hospital, that provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.

Although the initial POS description for code 11 includes ‘office,’ it is apparent that the complete POS code description does not exclude a dialysis center, as you mentioned. Therefore, POS 11 is not incorrect; however, POS 65 is more accurate.

Certainly, this is not a procedure that a provider would perform in an examination room at a physician’s office.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



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