Pathology/Lab Coding Alert

Don't let Medicare's new time frames catch you napping

Sometimes Medicare denies your claims for bundled tests--such as different surgical pathology CPT 88300 and 88305--even when you legitimately claim the two codes for two distinct specimens. 

After Jan. 1, if you neglect CMS' new appeals process guidelines described in a recent Medlearn Matters article (MM4019), you could miss your opportunity to claim payment that your lab deserves for 88300 (Level I--Surgical pathology, gross examination only) and 88305 (Level IV--Surgical pathology, gross and microscopic examination)--or any other bundled tests that you legitimately perform together.

Learn the Basics

When you get a denial, your carrier will still perform the first level of appeals--which will now be known as a
redetermination--and you'll have 120 days to request this level of appeal. You'll have 180 days to file a request for the next level of appeal, known as a reconsideration, which the Qualified Independent Contractor will perform.
After that, you have 60 days to request the third level of appeals, performed by the Administrative Law Judge (ALJ). In January, the minimum amount at stake for an ALJ appeal will go up from $100 to $110. If the ALJ doesn't go your way, you have 60 days to appeal to the Department Appeals Board. And after that, you have 60 days to appeal in federal court, as long as you have at least $1,050 at stake.

Minor errors: If you've just made a minor error on a claim that caused it to be denied, then you may not need to appeal the denial, CMS says. You can ask your carrier to reopen the claim so you can correct the problem, instead of going through the appeal process.

Pay Attention to Deadlines

Late filing: If you file a request for redetermination after the 120-day deadline, your carrier can still accept the request. Your carrier has until Jan. 1 to come up with a procedure for deciding whether you had a good reason to submit the request late, according to CMS.

The date for a redetermination request is the day the carrier's corporate mailroom receives the document, according to Medlearn Matters article 3942.

Heads up: Some experts are concerned that you may miss the deadline for requesting a reconsideration because you have 180 days, not six months, according to Tammy Tipton, president of Appeal Solutions in Blanchard, Okla. Remember: The 180 days includes weekends and will typically leave you a couple days short of the previous six-month guideline.

The most important change to the appeals process is the fact that you must submit your complete case, including all documentation, to the carrier at the first level. After that, you can only add more information for "good cause" or to correct clerical errors, says Deborah Churchill, RTT, president of Churchill Consulting in Killingworth, Conn.

Also under the new process, the carriers won't be able to collect any overpayments from you until they complete the appeals process--and only if they win.

Note: You can read the Medlearn Matters articles at www.cms.hhs.gov/medlearn/matters.