BlakeCarswell82
Guru
Is anyone else having this problem?
Humana has started to deny 88313 almost every time and sometimes the
G0461/G0462.
We are getting "Per LCD or NCD, CMS ID(s), L34631 documentation should be requested or reviewed for procedure code 88313."
Our documentation has been reviewed and was deemed to be sufficient for all other carriers. Even sending in medical reports has not helped.
I am aware of the CMS instructions in early 2014:
Scientific data demonstrates that the combined number of gastric biopsies requiring special stains is equal to or less than 20 percent of biopsies received and examined in a practice, laboratory, or hospital. Palmetto GBA agrees with
the published data. To check utilization, Palmetto GBA encourages providers to perform a self-audit on the number of separate gastric biopsies (reported with CPT code 88305) as compared to ancillary stains (reported with CPT
codes 88312, 88313, G0461, and G0462). The ancillary stain code group should be less than 20 percent of the total gastric biopsies (88305 codes) submitted.Providers that exceed the 20 percent criteria may be subject to additional action.
However, according to Dennis Padget:
Palmetto policy #M00097 was rescinded in late July or early August 2014.
Also, it is not just gastric cases, so it would not always apply.
Any information on this subject would be very helpful.
Thank you in advance.
Humana has started to deny 88313 almost every time and sometimes the
G0461/G0462.
We are getting "Per LCD or NCD, CMS ID(s), L34631 documentation should be requested or reviewed for procedure code 88313."
Our documentation has been reviewed and was deemed to be sufficient for all other carriers. Even sending in medical reports has not helped.
I am aware of the CMS instructions in early 2014:
Scientific data demonstrates that the combined number of gastric biopsies requiring special stains is equal to or less than 20 percent of biopsies received and examined in a practice, laboratory, or hospital. Palmetto GBA agrees with
the published data. To check utilization, Palmetto GBA encourages providers to perform a self-audit on the number of separate gastric biopsies (reported with CPT code 88305) as compared to ancillary stains (reported with CPT
codes 88312, 88313, G0461, and G0462). The ancillary stain code group should be less than 20 percent of the total gastric biopsies (88305 codes) submitted.Providers that exceed the 20 percent criteria may be subject to additional action.
However, according to Dennis Padget:
Palmetto policy #M00097 was rescinded in late July or early August 2014.
Also, it is not just gastric cases, so it would not always apply.
Any information on this subject would be very helpful.
Thank you in advance.