danachock
Expert
Hi, I am going to post this twice (here and in the pathology 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
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