Ob-Gyn Coding Alert

Question: A patient presented for an office visit with vaginal bleeding. During the examination, the ob-gyn performed a biopsy, which we sent to an outside lab that bills us. We reported this as 99214, 57500 and 88305, but Medicare refused to pay 99214 because it is not paid separately. It also wouldn't reimburse 88305, claiming the doctor was not certified or eligible. How can we get paid for these services?

Illinois Subscriber

Answer: Modifiers will make all the difference to your claim. To get your claim paid, you should add modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...). Similarly, you should append 88305 (Level IV - Surgical pathology, gross and microscopic examination) with modifier -90 (Reference [outside] laboratory).
 
Modifier -25 indicates that the E/M service was separate and significant from the procedure. And modifier -90 explains that you are billing on behalf of a lab that does have the correct certificate. Make sure you have noted the lab's identification number on the claim.