Wiki 88305 Bone Marrow cases to Humana

[atipton12]

We are billing pathology services for bone marrow cases. I have not been able to determine why Humana will deny 88305 or 88305x2 (bone marrow biopsy and/or clot) for bundling. We have called Humana and they are unable to tell us what it is bundling to. Does any else get this denial and have you determined why they deny with CO97?

Thanks!

 

[davehudgb]

I've worked for a pathology provider for a number of years and I have seen this denial too many times. The first question I have is this a Medicare replacement policy - if so you might need to be splitting the charges to the TC/26 Components. If you are not splitting them they will deny the 88305 in full. If they were split you might see a denial for the TC component and the 26-Professional charge will process. This denial will indicate that an outpatient facility, surgical facility or inpatient stay is being billed on the same date of your pathology service.

Another scenario would be what we use to encounter, The dermatologist completed two biopsies, he processed one within his office, billing the appropriate codes - let's say 88305. He then sent the second biopsy to us for prepping and analysis due to the complexity. We then billed the patients commercial insurance (Humana). We held our claims for 4 weeks, so we always seen the CO97 denial in this case. They will have already processed the claim for the dermatologist and our claim would get denied. We then had to file a reconsideration / claim dispute to explain the dermatologist completed two separate biopsies on two separate anatomical sites. Sometimes we were successful - sometimes not.

Usually insurance carriers will not indicate that another claim for that code has been processed. If you get a seasoned representative, you might ask them to verify if a facility claim or another provider is billing on the same day. They might confirm this for you.

 

[atipton12]

I've worked for a pathology provider for a number of years and I have seen this denial too many times. The first question I have is this a Medicare replacement policy - if so you might need to be splitting the charges to the TC/26 Components. If you are not splitting them they will deny the 88305 in full. If they were split you might see a denial for the TC component and the 26-Professional charge will process. This denial will indicate that an outpatient facility, surgical facility or inpatient stay is being billed on the same date of your pathology service.

Another scenario would be what we use to encounter, The dermatologist completed two biopsies, he processed one within his office, billing the appropriate codes - let's say 88305. He then sent the second biopsy to us for prepping and analysis due to the complexity. We then billed the patients commercial insurance (Humana). We held our claims for 4 weeks, so we always seen the CO97 denial in this case. They will have already processed the claim for the dermatologist and our claim would get denied. We then had to file a reconsideration / claim dispute to explain the dermatologist completed two separate biopsies on two separate anatomical sites. Sometimes we were successful - sometimes not.

Usually insurance carriers will not indicate that another claim for that code has been processed. If you get a seasoned representative, you might ask them to verify if a facility claim or another provider is billing on the same day. They might confirm this for you.

Thank you. We are billing the professional component and we are only seeing this particular denial from just Humana Medicare replacement policies on the 88305 on only bone marrow cases. It could be to the facility I suppose, but why just the 88305 out of all the other charges we are billing for that one bone marrow case.

 

[lisamc2372]

We are billing pathology services for bone marrow cases. I have not been able to determine why Humana will deny 88305 or 88305x2 (bone marrow biopsy and/or clot) for bundling. We have called Humana and they are unable to tell us what it is bundling to. Does any else get this denial and have you determined why they deny with CO97?

Thanks!

We have recently seen these denials as well. I have been working on appeal letters with each as I feel I will have better luck with an appeal than over the phone. But Humana Medicare is the only Medicare advantage plan doing this. And so far it is just Humana Medicare and not Humana commercial plans.