Question Bone Marrow Biopsy - denials

danachock

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Hi, I am going to post this twice (here and in the billing/reimbursement forum). I would appreciate any insight that anyone is experiencing with this please. Is anyone else receiving (how do I state this - except possibly obnoxious denials) with their Bone Marrow biopsies? Medica has been filling up the denial work queue and is driving me crazy with these appeals. I clearly believe that reviewing the denials that I have already reviewed the EOB and adjustment codes that something has to be amiss in their system. Like possibly a programming error. This has been going on for a while now.
Let me explain what is going on okay. I'm just going to throw some fictious CPT codes at this example.
85097
88305 x2 second charge with Modifier 59
88313 x2 second charge with Modifier 59
88311
88342x1 (with Modifier 59 for distinct/separate procedure from 88189 - (two different accessions with sometimes different pathologists and no overlap on panels ran or IHC performed)
88341x3
88189

Well in my evaluation of this - 88189 gets paid, 85097 gets paid with the special stains and also "sometimes" 88342 with 88341 gets paid > however they "bundle" both 88305x2 (for the clot and also the core) into something that I am not able to identify (stating: not separately payable/bundled) therefore they deny the 88311 for being billing without primary procedure because they denied the 88305x2 charges. It is when they deny pretty much everything except the 85097, 88313x2, and 88189 that I state the EOB is obnoxious and denying the majority of the charges.
Is anyone else seeing this type of scenario?
My second question is at what point (how many denials need to be reviewed - I need a # please like 25 cases or 50 or 100- before I ask my billing team to have a discussion with our representative on this issue?) Especially if I run my charges through our claim processor and those charges that need a modifier actually have it applied? I have reviewed off the top of my head so many at this point my billing team is probably getting tired of appealing all these but in my mind our pathologist's performed the work and should be accurately paid for those RVU's for their work. It is so common at this point that I know that if a decal or 88305 was denied by Medica and a quick review of the charges billed it was a Bone Marrow biopsy it is clearly another one of these scenarios.
Again, I so do appreciate any comments or feedback on these billing woes I have been faced with.
Have a fantastic evening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT
 

danachock

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Brainerd, MN
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Hi Good Evening,
Thank you everyone concerned about this issue. I just noticed it isn’t just our little facility battling these issues but may encompass yours. I clearly have to believe that this could be an area of interest for several colleagues "pathology coders" or "billers… along with otherwise" reviewing the number of reviews on this issue tonight and wanted to share my findings on this today okay.

Last night, I was personally reviewing pathology denials, these are denials I have already sent to the biller to appeal and to simply have these very same claims (invoices) again landed back in my denial WQ for further review had me displeased. Yes, I am not inconsiderate – so I reviewed their statements – they all state “Inv xxxxxxxxxxxx” (No PHI) stated that “website doesn’t indicate what claim bundled with”. I already stated in my original response to them for an appeal that “there is no clear bunding issue; (again from my research) they are denying us erroneously and we (our facility) need to appeal with notes that I have extracted from the pathology report and if they need additional proof from “Charge Assist” to EM (email me personally) for that spread sheet to show my proof of no bunding issues. I have CLEARLY seen so many denials on this issue (I kept it in draft mode addressed to me to make all my notes these past months). That is my homework – you keep the full name with HAR and the DOS to address common scenarios that maybe incorrect.

I was told by my billing team that Medica had a project plan implemented back in March on this to “reprocess claims”, but clearly that isn’t happening when I am battling denials from May 2022. Please be cognizant and run your “charge router review on this”, make sure “if” you are seeing this to contact your Medica representative immediately. Sometimes insurance companies make mistakes and well …. I guess we move forward.

My GOAL is to move forward. Anyone facing this ~ team up with your billing team

Please take advice from my note taking. If you found continuous issues and need to report it to your billing team, you will want this piece.

This is my personal advice, find out when Medica’s system was ultimately “broken” and demand that they honor this processing scenario that was actually correct. I am going to be absolutely horrible with this area. You send them absolutely everything, how they denied these accessions and expected payment, and none received. I wouldn't even bat an eye going more than a year's (+) worth. I couldn't be confident on my findings without enough truth "longevity" on these issues, the rights to discuss this with my billing team?

Again, thank you for reviewing this post, if you need additional help, please show your billing team my response or respond (I was on FMLA last fall when I noticed this), make sure you are checking your history please.
Thank you again for listening, anything you have to share is appreciated please.
Have a wonderful evening,
Dana Chock, CPC, CHONC, CPMA, CPMA, CPB, RHIT
 
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