Wiki Humana "Missing Required Modifier" Denial

[Lynn877]

I have a Gastro clinic billing 88305 for pathology services, and Humana is denying stating "Missing required modifier". They are billing the global charge. Does anyone know what modifier might be needed?

 

[sls314]

I have a Gastro clinic billing 88305 for pathology services, and Humana is denying stating "Missing required modifier". They are billing the global charge. Does anyone know what modifier might be needed?

Is it being billed with any other services? Depending on what else it's being billed with, it could be hitting an NCCI edit.

88305 is a Column 2 code for a few CPTs and would need an NCCI-modifier (if applicable) to be reimbursed.

I'd also compare how many units are being billed to the MUEs. (In my experience, sometimes an MUE could show up as a modifier or other denials, because theoretically you could try billing a modifier to override the MUE. If there was sufficient documentation, of course.)

 

[Lynn877]

Is it being billed with any other services? Depending on what else it's being billed with, it could be hitting an NCCI edit.

88305 is a Column 2 code for a few CPTs and would need an NCCI-modifier (if applicable) to be reimbursed.

I'd also compare how many units are being billed to the MUEs. (In my experience, sometimes an MUE could show up as a modifier or other denials, because theoretically you could try billing a modifier to override the MUE. If there was sufficient documentation, of course.)

It's on the claim by itself. I'm sure they are also billing the colonoscopy on a separate claim. The claim is coming back as a CO45 for the entire billed amount. The response to the claim inquiry said, "Payment is not allowed for this service because the procedure code billed is missing a required modifier." Could it be as simply as a 59 modifier?

 

[OpenClaims]

According to this CMS document (LABS - CM), 88305 may require a TC modifier. I would look into that. I don't have my CLIA list on hand, but also make sure the 88305 doesn't require a QW modifier.