New Year, New Edit for TC of Pathology Services

Medicare contractors will implement April 4, 2011 a new edit that the Centers for Medicare & Medicaid Services (CMS) hopes will prevent the technical component (TC) of pathology services to be improperly billed by any entity other than independent laboratories (ILs). Contractors will use updated remittance and remark codes to notify providers of denied claims.

Payment for the TC of physician pathology services provided to a hospital inpatient is included in the bundled payment, with the exception of ILs (specialty code 69). Effective April 1, 2011 contractors are instructed to deny the Part B TC or globally billed physician pathology service line items that should be bundled to the hospital.

Contractors will use claim adjustment reason code (CARC) 96 Non-covered charges along with remark code (RC) N70 Consolidated billing and payment applies on the remittance advice (RA) when denying a service line item for a Part B TC or globally billed radiology and pathology service with a service date that falls within the admission and discharge dates of a covered hospital inpatient or outpatient stay. The real tip off will be the Medicare summary notice (MSN) message 13.12 Medicare Part B doesn’t pay separately for this item/service. Payment for this item/service should be included in another Medicare benefit. The hospital/nursing facility must bill for this Medicare service.

Contractors can override the edit in the event a denied claim is appealed successfully by the provider.

Source: CMS Transmittal 795, Change Request (CR) 7061, issued Oct. 29.

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