Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that when completing the 1500 claim form, providers must enter the correct Place of Service (POS) code in section 24B. Invalid or incorrect POS codes will be denied and returned to the provider. You can find this rule at Medicare Claims Processing Manual Ch. 26 Section 10.6.

The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I.

The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. You can find this rule at 42 CFR Section 424.5.

The plan must follow Medicare rules. Medicare rules say that providers must submit appropriate place of service codes. In this case, you submitted a Place of Service code of 32, which is the appropriate POS code for enrollees who are considered residents in a SNF. The plan stated the POS should be 12. Per Medicare guidelines, POS code 12 is strictly for the home, and does not include a facility as a home, even if the enrollee is a resident of the facility. Therefore, the plan has to pay for DME supplies provided to the enrollee.

Medicare guidance says 11 Office 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. You can find this guidance in the Medicare Claims Processing Manual Chapter 26 - Completing and Processing Form CMS-1500 Data Set, 10.5 - Place of Service Codes (POS) and Definitions. Medicare guidance says The A/B MACs (A) must provide a listing of the required data elements,
including a brief explanation to providers and suppliers. A/B MACs (A) must educate providers regarding the distinction between submissions which are not considered claims, but which are returned to provider (RTP) and submissions which are accepted by Medicare as claims for processing but are not paid. Claims may be accepted as filed by Medicare systems but may be rejected or denied. Unlike RTPs, rejections and denials are reflected on RAs. Denials are subject to appeal, since a denial is a payment determination. Rejections may be corrected and resubmitted. You can find this guidance in the Medicare Claims Processing Manual Chapter 1 - General Billing Requirements Section 70.2.3.2 Handling Incomplete or Invalid Submissions.

Medical Guidance says If a laboratory procedure produces multiple reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. If there is no HCPCS/CPT code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. You can find the information in the Medicare Local Coverage Article: Billing and Coding: MolDX: Testing of Multiple Genes (A57880) and Medicare NCCI Coding Policy Manual - Chapter 10 - CPT Codes - 80000-89999.

Medicare guidance says "Unless otherwise specified, the MAC, RAC and ZPIC/UPIC shall request information from the billing provider/supplier. The treating physician, another clinician, provider, or supplier should submit the requested documentation. However, because the provider selected for review is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC, CERT, RAC and ZPIC/UPIC." Medicare Program Integrity Manual, Chapter 3 -Verifying Potential Errors and Taking Corrective Actions, Section 3.2.3.3 - Third-party Additional Documentation Request.

The rules say that if the physician bills for lab services performed in his/her office, the POS code for "Office" is shown. If the physician bills for a lab test furnished by another physician, who maintains a lab in his/her office, the code for "Other" is shown. If the physician bills for a lab service furnished by an independent lab, the code for "Independent Laboratory" is used. Items 21 and 22 on the Form CMS-1500 must be completed for all laboratory work performed outside a physician's office. If an independent lab bills, the place where the sample was taken is shown. An independent laboratory taking a sample in its laboratory shows "81" as place of service. If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it uses the code for the inpatient (POS code 21), off campus-outpatient hospital (POS code 19), or on campus-outpatient hospital (POS code 22), respectively. You can find this information in the Medicare Claims Processing Manual; Chapter 26 - Completing and Processing; 10.6 - A/B Medicare Administrative Contractor (MAC) (B) Instructions for Place of Service (POS) Codes.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.