Wiki Denials for POS for specimen collected in physician office

[kandieverett]

We have been receiving Medicare denials for surgical pathology codes. The remark code is M97-Not paid to practitioner when provided to patient in this place of service. Payment included in the reimbursement issued the facility. And CO-97 The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Example: Pt was seen by her GynOnc and had an office visit and biopsies. Codes billed by the md for the visit were 99214,46606,56821. The pathologist billed 88305. We are a large group practice (cancer center) and we bill POS 11 for all charges. The biopsy was performed at one location and the path at our dedicated path location.

Can anyone help me understand why we are receiving this denial? There are no CCI edits and I cannot find any other guidance. Please help! We do multiple biopsies per day and I am seeing this denial often. Our MAC is Palmetto

Thank you,
Kandi Mardis COC,CPC,CHONC

 

[thomas7331]

Are you billing the professional or technical component or both?

If the MD performed the surgery and took the biopsy specimens in a facility in your example, then the technical component would be inclusive to the facility' payment for that procedure. So if your provider is performing the technical component, then I believe you would need to invoice the facility for that portion.

 

[kandieverett]

The gyn took the specimen in the office and then sent the sample to our pathology location. We bill the charges as global. We have pathologists on staff who are located at a separate office location. The specimens are collected at a separate location. There is no "facility" involved in a collection or testing capacity.

 

[SharonCollachi]

It sounds like your office is not set up as a path lab with Medicare. However, you said this:

"Codes billed by the md for the visit were 99214,46606,56821. The pathologist billed 88305." So which charges were denied? The endoscopy procedure or the pathology procedure?