Wiki 88305

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skumar

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Hi,

Suddenly I am having some denials on 88305 when I code in the following way.

There are 4 different 88305 level specimen services provided and I have coded them with;

For professional:

88305-1-26
88305-3-26-59.

This is how I am following. Kindly advise on the common coding way to code multiple specimens.

Thanks
skumar
 
88305 billing woes

Hi Skumar,
You are coding it correctly for multiples for the majority of payers I bill. This is common practice for me.

Did they deny all four charges or did they pay one and deny the rest as dupes? Who is the denial from? What does the EOB state? What is your adjustment code(s)? Has anything changed at your facility relating to how you bill? Has a new pathologist been added (possible credentialing issue?) I need a little more information to provide any advice.

Thanks,
Dana Chock, CPC, CCA, CANPC, CHONC, CPMA, CPB
Anesthesia, Pathology, and Laboratory Coder
 
Hi Dana,

The payer is Amerihealth, DC Medicaid. They denied the 1 line item 88305-1-26 saying as duplicate and paid the other 88305-3-26-59.

Can I follow the same what I am coding now or I need to change my coding for the payer prefernce.

Thanks
skumar
 
88305 denial

Hi Skumar,
Unfamiliar with Amerihealth, DC Medicaid - this would warrant a phone call to find out why the quantity 3 was paid and the quantity 1 wasn't. This is important. The information you find out is invaluable and may affect how you bill 88305 to them in the future, with that being said that is why it's important to find out how they want it billed so reimbursement is faster, less denials to work and less time spending on working appeals. They may be one of those payers that require a single line item with quantity and the 59 modifier.
Good luck and have a great evening.
Thanks,
Dana
 
For some reason 88305 is flagging for an LCD Policy for me w/ Novitas. Seems that if the pt doesn't have cancer - they won't pay for it??
 
EOB woes

Hi,
Please read the entire EOB, they can tend to be long and several pages. Look at all the pages. Usually/typically the final page will list the codes they apply and the reason why it was denied.
Also take a peek at the back ground, the office visit or ER visit and make sure it wasn't auto related. If it was auto related it may need to be billed to TPL instead of their primary insurance carrier.
Thanks,
Dana Chock, CPC, CCA, CANPC, CHONC, CPMA, CPB
Anesthesia, Pathology, & Laboratory Coder
 
how do you code 88305 with 32 different specimens? If specimens are of same region i.e. 4 different specimens from right Apex and 4 different specimens from left Apex for same DOS by same Provider, would you count as 8 specimens or just 2?
 
Hello aamipatel,
Yes, those are those "whoppers" in my opinion. If the surgeon sends me Specimens A through AF. There may clearly be 32 different charges. I have worked for healthcare facilities that surgeons have clearly performed "hail Mary's" life saving measures on patients. Always tumor or malignancy related.
Each specimen is individually accessioned and separately identifiable from the rest of the specimens.
They, the surgeon, needs to ensure that "margins" are clear if you are wondering why.
Every neoplastic process requires certain "margin" requirements. I am not a surgeon or pathologist, only a coder.
The pathologist is also performing intraoperative rapid frozen sections, possible intraoperative touch preps.
No, if you count 4 from right apex and 4 from left apex without seeing your pathology report and they gave you specimen A, B, C, D, E, F, G, H.
Those ~ are all completely "different" specimens from one another from your post. You bill whatever surgical pathology codes necessary to have 8 surgical pathology charges total.
Please reach out to me if you have any questions. Whoppers are not fun.
Dana
 
danachock said:
Hello aamipatel,
Yes, those are those "whoppers" in my opinion. If the surgeon sends me Specimens A through AF. There may clearly be 32 different charges. I have worked for healthcare facilities that surgeons have clearly performed "hail Mary's" life saving measures on patients. Always tumor or malignancy related.
Each specimen is individually accessioned and separately identifiable from the rest of the specimens.
They, the surgeon, needs to ensure that "margins" are clear if you are wondering why.
Every neoplastic process requires certain "margin" requirements. I am not a surgeon or pathologist, only a coder.
The pathologist is also performing intraoperative rapid frozen sections, possible intraoperative touch preps.
No, if you count 4 from right apex and 4 from left apex without seeing your pathology report and they gave you specimen A, B, C, D, E, F, G, H.
Those ~ are all completely "different" specimens from one another from your post. You bill whatever surgical pathology codes necessary to have 8 surgical pathology charges total.
Please reach out to me if you have any questions. Whoppers are not fun.
Dana
Click to expand...
thanks for explaining, it certainly is "whoppers", surgeon do send different specimen A through AF. we have clear report mentioning they are separate biopsies. now my confusion here is how to code procedure 88305 for 32 specimens. As allowed MUE for 88305, i 16 only. I have Humana payer for this particular case. My research told me to go with G0416 instead, as it meets the Humana requirements. Pleae advise.
 
Hello aamipatel,
It really depends here. I do need a little additional information to assist you please.
Are we dealing with prostate biopsies to warrant billing G0416? I do see you used the term "apex" above but didn't know for sure on the specimen or specimen(s) being reviewed to make that assumption until now.
HCPCS G0416 "Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method".
Were all the biopsies from the prostate, or were there other locations also included? I typically see 12 being done at a single procedure setting; but that has varied and wanted to be sure I had the correct information.
This of course is in my opinion, but 32 specimens seem like a large number of biopsies if it was all focused on the prostate.
If they were all prostate biopsies, and from your review on Humana determine that the G0416 is more appropriate based on your research. Some insurance companies require G0416 over 88305 x number of specimens.
Thanks,
Dana
 
danachock said:
Hello aamipatel,
It really depends here. I do need a little additional information to assist you please.
Are we dealing with prostate biopsies to warrant billing G0416? I do see you used the term "apex" above but didn't know for sure on the specimen or specimen(s) being reviewed to make that assumption until now.
HCPCS G0416 "Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method".
Were all the biopsies from the prostate, or were there other locations also included? I typically see 12 being done at a single procedure setting; but that has varied and wanted to be sure I had the correct information.
This of course is in my opinion, but 32 specimens seem like a large number of biopsies if it was all focused on the prostate.
If they were all prostate biopsies, and from your review on Humana determine that the G0416 is more appropriate based on your research. Some insurance companies require G0416 over 88305 x number of specimens.
Thanks,
Dana
Click to expand...
Hi Dana, Sorry for replying late on this one. this was the prostate biopsy case and I processed it with G codes on them. thanks a ton for helping me out here, appreciate the help. Thank you
 
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