Wiki 88305-TC / 88305 denials

[phastings]

We are having problems with Medicare requesting refunds for CPT 88305-TC and 88305 using the reason the patient was in a outpatient hospital. We believe this is happening because the edit logic is checking against the referring physician listed on the claim. In the past we named the actual physician who referred to our clinic. We fixed the problem on our end and have started listing our physician as the referring physician for CPT 88305. The problem remains on the previously denied claims, Medicare denied our appeals and we were told a mass adjustment would be done but it did not capture the claims that had the wrong referring physician. We have tried redetermination, reopening, and refilling, to list our physician as referring and to have claims reprocessed without success. Any suggestions?

 

[bethb]

I have a very similar situation--we are not receiving refund requests, but the total component billing of 88305 will many times be denied by Medicare because the patient was an outpatient at a facility on the same day. I've done extensive research, many hours trying to find rules and regulations, and there is not a lot out there.

The denial is very similar to a Skilled Nursing Consolidated Billing or Home Health Consolidated Billing.

If the patient was an outpatient at a facility at any time of the same day of an in-house lab was done by a physician (Part B billing), i.e. lab 88305 done in the physician's office--then Medicare will only reimburse for the professional component of the lab. We have had to re-bill ours as 88305-26, which I do not think is fair, but because of the consolidated billing rules, only the professional component is paid.

I hope this helps.