Wiki PERIPHERAL SMEARS

[Lupita1983]

Does anyone know why Medicare and any insurance that follows Medicare guidelines refuses to pay for CPT 85060 in an outpatient setting? Do I need to add modifier 26 for billing the professional component only? I don't see why I would need mod 26 if this exact CPT is for interpretation and report which sho

Hypothetical case:
Patient has a PCP visit (location 3), PCP orders lab tests (CBC not done in clinic). The patient goes to local hospital where blood is drawn and results send to PCP. Results show low platelets, low MPV, low lymphocytes, etc. so the PCP submits an add-on test for a peripheral smear. The blood is smeared into a slide and sent to our pathologist to interpret. Our pathologist reports as follows:

Clinical Information
Preoperative diagnosis: Cirrhosis
Clinical history: Peripheral smear examination is performed at the request of Rebecca Mabie DO, for evaluation of this 61 year old female.
CBC results from 04/22/24 demonstrate thrombocytopenia.
Findings
Peripheral Smear:

Thrombocytopenia. (See comment)
Comment
Thrombocytopenia with giant platelets is suggestive of peripheral platelet destruction/utilization or splenic sequestration. Clinical correlation is recommended.
A: CBC Results

WBC 4.55 K/uL
WBC 5.36 K/uL
RBC 4.26 M/UL
RBC 4.27 M/UL
Hemoglobin 13.0 G/DL
Hemoglobin 13.0 G/DL
Hematocrit 37.9 %
Hematocrit 38.0 %
MCV 89.0 fL
MCV 89.0 fL
MCH 30.5 pg
MCH 30.4 pg
MCHC 34.3 G/DL
MCHC 34.2 G/DL
RDW - SD 43.2 fL
RDW - SD 43.0 fL
RDWCV 13.4 %
RDWCV 13.3 %
Platelet 86.0 K/uL LOW
Platelet 90.0 K/uL LOW
MPV 9.2 fL LOW
MPV 9.1 fL LOW
NRBC % 0.0 /100WBC
NRBC % 0.0 /100WBC
NRBC Absolute 0.000 K/uL
NRBC Absolute 0.000 K/uL
Automated Segmented Neutrophils 64.1 %
Automated Lymphocytes 25.1 %
Automated Monocytes 6.2 %
Automated Eosinophils 3.3 %
Automated Basophils 0.9 %
Automated Absolute Neutrophils 2.92 K/uL
Automated Absolute Lymphs 1.14 K/uL LOW
Automated Absolute Monocytes 0.28 K/uL
Automated Absolute Eosinophils 0.15 K/uL
Automated Absolute Basophils 0.04 K/uL

Our pathologist does not work for the hospital, therefore, we submit charges independently, but Medicare denies for OP or Loc 3 (when blood is drawn at the clinic). Do I charge the PC to the hospital instead of the insurance? Should I submit 85060 with a 26 modifier? Am I doing this all wrong or is this just the way it is and my pathologist works for free?

I really do appreciate the time and guidance. Thank you.

 

[danachock]

I wholeheartedly apologize Lupita1983
I did not need to even look at your example in an outpatient setting. 85060 is denied all day long by CMS. It is deemed an inpatient only specimen. If it is commercial you may get reimbursed.
Maybe it is time to explain why an outpatient 85060 is medically necessity for NCCI?? It is probably we as "coders" unite to state to NCCI that they are erroneously wrong here??
Let me know??
I personally have never gone that path before, but I know that the providers are doing everything, correctly interpretating charges BUT AT THE END OF THE DAY NCCI STATES IT HAS TO BE INPATIENT has clearly blown my mind for years here. Have you ever been to the Emergency Room?? Do you know how many hours you could be there? Have you been in an outpatient procedure this was performed. You weren't sick enough to be ADMITTED BUT THEY DID THIS PERIPHERAL BLOOD SMEAR and you are sitting your happy ass in a hospital bed in the "outpatient" POS 22 waiting to go home.
Thank you for listening,
Dana