Pathology perfmed in Office setting when patient was also in hospital the same day


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This comes up often in dermatology on occasion and I understand the reason for the initial denial. Looking for the solution here.


Patient received services in a hospital setting in the morning (let's say it's outpatient)
Patient goes to dermatology office in the afternoon (for an unrelated matter) and has biopsy and pathology performed (in the office setting POS = 11)

Claim is denied by Medicare stating the consolidated service rule where technical services cannot be billed separately when a patient receives Part A services.

I understand that this is covered in this CMS bulletin...

However, since the services were performed in a physician's office (independent of the reason for the hospital visit), is this rule still applicable? (If so, then I assume the derm bills for the professional component directly 88305-26 and bills the hospital for the 88305-26?)

If, not how does the client get the denial or appeal reversed? Just an appeal with a cover letter stating that the services were independent of any hospital stay and were performed in the office setting?