M97 Medicare denials


Benton, Arkansas
Best answers
I do billing for a pathology lab, and we are receiving denials from Medicare that state "M97-Pmt included in facility reimbursement". When I call Medicare to ask about this, each time I'm told that the patient was receiving outpatient services at a facility (usually a local hospital) for a specific date range that our date of service happens to fall into. Our charges are completely separate from the outpatient services, and Medicare recommends I file a corrected claim with a modifier to support that our charges are separate. I'm unclear on what modifier would be best to use for this as I have no idea what kind of outpatient services the patient is receiving, just that the specimens we processed did not come from that facility. Looking at the basic definitions, XP or XE either one look correct, but digging deeper, both look to only be useful for separate charges performed under a single NPI, which is not the case here. Any recommendations are welcome...
Are you certain that your labs services are unrelated to the hospital's services? In other words, ordered by a different provider and for an unrelated diagnosis than that for which the patient sought treatment at the hospital? If you know for sure that's the case, then I think perhaps the reps are your Medicare contractor are giving you incorrect information. I'm not aware of any modifier that would accomplish this. I agree with you that modifiers such as 59, XP, XE are for unbundling services by the same provider - they're not for unbundling one provider's services from a different provider's claims. In this particular situation, the modifier a hospital would use to show that labs are unrelated is modifier L1, however this modifier is only for use on a UB form, as far as I know, so I don't think that's a possibility for you. I think that their asking you to bill a corrected claim with a modifier makes no sense - how can you assign a modifier without knowing what another provider has billed? No one can code based on records that they don't have. In your place, I would escalate this question to someone at Medicare who can give you better guidance, or else appeal with a copy of your order that would show that your labs were ordered by a different provider and diagnosis and aren't related to the hospital services.

On the other hand, if in fact these labs are related to what happened at the hospital, then you would need to contact the hospital and arrange to bill them for the charges as they would be inclusive to the APC rate that the hospital received from Medicare and it would be the hospital's responsibility to reimburse you.