Pathology/Lab Coding Alert

Watch those dates of service, MAC addresses, and more.

When it comes to billing issues, Medicare payers have been issuing warnings for years about the most common errors, but many labs haven’t updated their processes to account for the most recent updates. This can lead to claim rejections and denials — which mean lengthy and time-consuming appeals for your practice to create, submit, and process.

Your best bet is to avoid some of the most common Medicare billing errors so you can submit clean claims and bring in accurate pay every time. Check out eight common errors, along with tips to avoid making these mistakes in your laboratory or pathology practice.

1. Only Confirming Patient Eligibility Once a Year

Although denials due to patient eligibility most commonly happen in January, they can strike any time of year. For instance, if a patient moved across the state line, you may need to submit their claim to a different Medicare Administrative Contractor (MAC). Or patients who are new to Medicare mid-year may tell you they have original Medicare, but you later find out that they’re actually part of an Advantage plan.

Solution: The best way to verify this data and avoid errors is to confirm every patient’s eligibility at every visit, and not just once a year. You should make a copy of their insurance card or scan it into your system and then confirm their eligibility in the plan before rendering services. Don’t wait until you get a denied claim before you start investigating whether a patient actually has the plan they claim to have.

2. Leaving Details off a Claim

3. Missing Filing Deadlines

Every practice thinks they’re on top of filing deadlines, but the MACs say they return tens of thousands of denials every month due to practices missing the claim deadline. This is probably among the easiest mistakes to avoid — you just need to keep your eye on the calendar. And always remember that if your claim is denied due to missing the filing deadline, you have no appeal rights. That claim is reduced to zero, and you have no option to collect.

Solution: You have one year to submit claims to Medicare payers, so never take longer than that. Some practices may set a claim aside because they’re awaiting additional information — and then forget to follow up later, letting the claim fall through the cracks. By the time they realize the claim remains unpaid, they submit it too late. The best way to avoid this error is to always monitor your billing process and follow up on any unsubmitted claims right away.

4. Failure to Confirm Provider Eligibility

After you go through the credentialing and enrollment process for your pathologists, you may still need to take additional steps in the future to ensure they stay credentialed and enrolled. And if their NPI expires, or you miss a reenrollment or credentialing deadline, your claims could be dead in the water.

Solution: Always put provider credentialing and enrollment deadlines on your calendar and start the revalidation process several months before the deadline approaches. This can be helpful since you may find errors or issues that need to be resolved during the application process. Plus, you won’t always get an approval overnight — there’s sometimes a delay. By starting early, you’ll have better odds of ensuring that your provider revalidation process is complete before it’s due.

5. Mismatching Your Modifiers and Procedure Codes

If your procedure code is inconsistent with the modifier used or the modifier was missing from the claim, your payer will send you a denial.

Solution: Always check your LCD and NCD, as well as the National Correct Coding Initiative (NCCI) table to see if you’re even able to use a specific modifier. If not, check whether an alternate is required or available.

6. Using Incorrect or Deleted Codes

You must ensure that you’re reporting accurate, up-to-date, and complete ICD-10-CM diagnosis and CPT^® procedure codes. If your claim includes codes that have been deleted, revised, or expanded upon and you don’t report them accurately, you’ll face denials.

Solution: Verify that you’re using the most timely and updated codes, and stay on top of the quarterly updates to the NCCI changes. In addition, when you report an ICD-10-CM code, it must be documented in the patient’s record that the patient has that condition. You can’t just put an ICD-10-CM code on a claim because it’s payable.