The Office of Inspector General (OIG) Office of Audit Services has identified acute stroke and sepsis as not supported in an outpatient setting. These conditions are typically treated in an inpatient hospital setting and rarely, if ever, occur in an outpatient setting.
EmblemHealth and ConnectiCare recognize the need for accurate coding and documentation. It’s an important part of patient care. We have taken the OIG Office of Audit Service findings into consideration and are making updates to our claims processing system.
Starting Dec. 6, 2024, we will deny any claims that have a diagnosis of acute stroke (I63.-) or sepsis (A41.-) when billed with the following place of service (POS) codes.
- Office (POS 11).
- Telehealth (Use POS 2 when patient and provider are in a facility; POS 10 for patients at home).
- On Campus - outpatient hospital (POS 22).
- Skilled nursing facility (POS 31).
- Federally Qualified Health Center (POS 50); Off-campus outpatient hospital (POS 19).
The denial reason will be listed as “diagnosis/place of service mismatch.”
We appreciate your assistance with this important issue. If you have questions or concerns, sign in to emblemhealth.com/providerportal or connecticare.com/providerportal and please use our live agent chat or Message Center to contact us. A Provider Customer Service representative will be happy to help.
See coding edits policies:
ConnectiCare: Coding Edits Policy
EmblemHealth: Coding Edits Policy
Thank you for your partnership and the care you provide our members.
JP66620 08/2024