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eccm7862

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Our providers are reviewing pathology slides from an outside provider for a second opinion. CPT 88321 (Consultation and report on referred slides prepared elsewhere) is being billed on the providers side without any modifier and getting denied for lack of modifier. These are primarily from UHC Medicare Advantage and commercial. Does anyone know if modifier XP would be appropriate to billed for this scenario?

Thank you
 
Hello eccm7862,
This post may be lengthy, but I clearly know what is happening here.
Let me try to break it down so everyone can understand it please here.
Patient XXXXX has procedure core biopsy of their neck for a lump at ZZZZZ facility on 4/29/2029.
It is sent to the pathology department by the surgeon with reason for visit a lump on neck R22.1.
Dr. Cookie Monster isn't fully sure what is going on; sees atypical cells this is stated within Dr. Cookie Monster's final interpretation and requests a consultation from outside from this lymph node core biopsy they need another set of eyes (pathologists from ABCDEFG facility that specializes in this specialty here) on this accession and sent slides and a block to this to other facility for an outside consultation.
Outside Consultation from facility ABCDEFG bills with same DOS 4/29/2029 as retrieval from ZZZZZ facility (not the acquisition date of 5/1/2029, but actual date the specimen was acquired).
Please know that no one is wrong here. This coding scenario is based on healthcare internal policies and billing guidelines.
But now the referring facility ABCDEFG does a bill back to your facility and you posted the charges, like what 30-45 days later to bill the patient here.
Dr. Cookie Monster already billed out 88305x1, 88342x1, 88341x10 after performing his addendum from ABCDEFG's pathologist's analysis and now your facility is billing 88321 with same day of service.
That is when there is a problem.
The Consultation 88321 from ABCDEFG facility with same DOS trumps the rest of the charges. You would need to correct the previously invoiced claims. 88305x1 with 88342x1 that would both require modifiers, and they state 88341x10 charges doesn't require it, but I know our insurance payors. Be super cognizant here. Just because you corrected the claim once and it is denied again that you cannot fix the claim and repeat this process within the correct claim time limit here.
Personal advice - please watch those 88341 charges like a beady eyed hawk to be sure. Personally, I'm so tired of small balance write offs that billers can make. I'd be happy to discuss in another AAPC post, but I believe I provided some pathology coding insight that may be needed for this coding scenario.
If you have other advice here, now would be the time to share please.
Have a fantastic evening,
Dana
 
Thank you for this information Dana. I further reviewed and the claims we are billing are not being billed with the same DOS of when it was collected. Example: 6 slides from 6/8/2023 and we our pathology review on DOS 4/5/2024. Do you think it would be appropriate to bill with modifier 26 since it is for the professional service?
 
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Hello eccm7862,
No, adding Modifier 26 would be inappropriate here.
88321 has a PCTC indicator of 0. Feel free to research this.
It is not a split charge (one that requires Modifier 26 or TC). You bill 88321 alone, except when other pathology charges may have been billed that very same DOS and requires a modifier(s). But not modifier 26.
UHC can be a pain and horrible to deal with (I have two of UHC's numbers still programmed in my phone dealing with denials a few years back); has anyone from your facility actually tried calling and asking them exactly what the billing issue is here creating the denial? I know it seems pretty easy, but waiting for representative with all the information to ask questions can be time consuming. But I know that pathologists are reviewing their RVU's. They want to know why they are not getting paid for services they rendered providing a consultation.
Did you review UHC's policy for whatever area/state you are trying to bill to see what their requirements are for billing a consultation?
What does the EOB actually state? They (UHC) have to tell you the reason(s). There may several denial codes. Do you have a claim that you could review and just share all the reasons? Is it consistent with all your denials?? Sometimes those denial codes and reasons seem gibberish but sometimes having another set of eyes may help identify the issue??
I again apologize for being lengthy in my post. But again, reiterate that pathologist's really do watch their RVU's carefully through the whole revenue cycle (what is in the pathology coder's work queues that needs to be worked, what is in the billers' work queues that still need to be worked, what pathology claims have been sent to Insurance Payors for possible payments, and also the denial work queues - why were they denied).
If there is anything I can do to possibly help you, I sure will.
Just know that I understand the frustration with denials and trying to figure it out. Which State (or States) are you billing 88321 to UHC? Maybe a quick review of UHC's policy may shed light on the requirements.
Hang in there and we will circle the wagons as we figure this out okay.
Dana
 
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