billing 88360, 88342, 88341

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our facility just now capable of running ER/PR/HER2NEU, my question we are getting denied 88342, 88341 for regular IHC stains? Curious to see how other facilities bill these cpts. We have medicare plans and commercial insurances denying 88342 and 88341? We do add modifier 59 to these 2 cpts. Any help would be great.
 

pcordill

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Torrance, California
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Are you familiar with the CMS NCCI edits? It's helpful to have this resource available for review to verify when you have a situation like this that requires a modifier when certain CPTs are billed together. CPTs 88342 & 88341 require a modifier to be billed with 88360. You should add modifier 59 if billing a commercial carrier or modifier 59 or XU if billing to Medicare.

Link to NCCI edits: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/PTP-Coding-Edits
 
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yes ncci edits some but we are billing the 88342 and 88341 with the 59 modifier but they still deny them; they do pay however the 88360 without a mod; do i have to appeal with our reports to show the different antibodies billed.
 

pcordill

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I would suggest using the XU modifier but if you are billing with the 59 on 88342/88341 I'm surprised that you are getting denied. Are you billing each CPT on one line with a quantity (e.g. 88342 X2, 88341 X10)? You also can't bill more than 4 units of 88342 or 13 units of 88341. What exactly is the remark codes on the EOMB?
 

danachock

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Brainerd, MN
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Hi, when we bill 88360 with 88342 and 88341 we follow Medicare guidelines for all payors and bill both 88342 and 88341 with a XU modifier. May I ask what state you are billing in? In two of the several states I bill for both 88342 and 88341 have a LCD to actually meet "medical necessity". Yes, I know it is a "permissive edit" but some payors may be following this and denying both 88342 and 88341 for not meeting medical necessity whereas 88360 doesn't have any LCD's.

Policy Number:
A54996

I have had to appeal sending the pathology report to state why a E-cadherin was applied (which is a test that the pathologist might use to help determine if the tumor is ductal or lobular.) or smooth muscle myosin heavy chain (SMMHC) is another common one I see among a few other IHCs. It is extremely important for the pathologist to state either in the microscopic area of the pathology report or in the IHC table why the IHC was performed - either "rule in/rule out", confirm xxxxx, or validate xxxxx such and such diagnostic finding to support billing those charges. This is especially useful when we are faced with a denial and need to appeal.

Thank you for listening and have a wonderful evening,
Dana
 

necruz

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Good morning Danachock - In regards to the questions you have asked Irma (we work together), the state we work in is Texas.
 

danachock

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Hi necruz,
I just checked and Texas (Jurisdiction H both Part A or B) doesn't have any LCD's for 88342 - I just want to be thorough; are you billing in Texas or to a different state? For example I code for Fargo, ND (North Dakota) and depending on the payor the claim may be processed in North Dakota that has LCD's or it may be processed for example in MN depending on the payor. Depending on your scenario and if utilizing Modifier XU or 59 and what payor you are billing. I will clearly fall onto the pathology report to support these charges and appeal. Please do not be afraid. That is why when you review the charges initially that the pathology report has to support billing all those charges. If something is amiss. Send that query and request that an addendum is completed (unless otherwise stated by pathologist - "the IHC was found not noncontribuatory so not billing for it", "or possibly ordered in error", etcetera Just please make sure your pathology report supports billing all your pathologist's charges.
If you need anything please reach out & have a wonderful evening,
Dana
 
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