Wiki Recent Pathology Denial Trends

danachock

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Hi Pathology Colleagues,
I wanted to address a few recent denials I am seeing and alert you so that together, we can be proactive coding these scenarios.

First, you receive the EOB (Explanation of Benefits) that states "Principal diagnosis is missing".
From my research these cases are being denied because the claim was billed with diagnosis codes that have a "Excludes 1" edit from our ICD Book.
This is not an exhaustive list, but I wanted to share some of the cases I have encounter working these pathology denials.
Example 1: K63.5, D12.5
Example 2: I31.4 (solo diagnosis)
Example 3: N81.2, N81.10, N81.6
Example 4: C15.9, K22.70
Example 5: N87.0, R87.612, N72
Example 6: N60.11, N60.81, N60.31, N60.91
Example 7: N84.0, N85.01, N84.8
Example 8: K81.1, K82.4
Example 9: J35.1, J03.90, J35.01
Example 10: K80.10, K82.4
Example 11: C43.59, D03.59
Example 12: D06.9, R87.619
Example 13: N87.1, D06.9
Example 14: C50.911, D05.11
Example 15: K76.0, K75.81, K74.01

Second you receive the EOB that states "this/these diagnosis code(s) are not covered". The insurance companies have become possibly savvy on how they process claims.
Therefore, if you bill procedure 88305 with a hemorrhoid charge K64.9 - that is one of the reason's I saw this scenario. The insurance companies have the resources and edits in place to know that if you bill a hemorrhoid charge it should have been billed with 88304 instead of 88305. Same thing with a ganglion for example M67.441 was incorrectly accessioned with 88305 and should have been billed with 88304.

Just a polite reminder to be cognizant when assigning your diagnosis code(s). Take the time to review your ICD book for those important "Excludes 1" notes. Also be sure to be reviewing the specimen at hand and provide the proper CPT code assignment such as lipoma with procedure 88304 or skin tag with 88304 instead of 88305. But, whenever in doubt, please reach out to your pathology team. Again, if something was not accessioned correctly for example a TURBT was reviewed and documented in the pathology report but 88305 was populated for the charge, that would be incorrect. You would want to bill 88307 for this service. Another example I frequently see is a pancreas biopsy billed with 88305 instead of 88307 along with liver biopsy. It could clearly be an accessioning issue - a new person just joined the team, or the pathologist was busy and failed to update a procedure 88305 to 88307 or from 88304 to 88305 or vice versa. Just be sure to query those accessions and ask those questions please.

In summary- by being proactive on the frontend when coding, this eliminates those denials. You spend the time and resources reviewing the charges so let's focus on billing it correctly with the correct diagnosis code(s), and procedure(s) and query the pathologist when in doubt and bill the claim correctly the first time. It saves a huge amount of time and resources on the backend working denials and reviewing documentation, possibly querying the provider, and correcting the claim which ultimately causes delays in the health care facilities revenue cycle.

If anyone else has recent pathology related denial issues that have identified and would like to share, I encourage you to do so.
Or if you have questions, please reach out and inquire.

Have a fantastic evening!
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT
 
Hello Lynne Morris,
Baby A needs to be distinguished from Baby B. I usually see the first baby born with a single clamp, whereas second baby receives two clamps to separately identify them.
Please do not be hung up on clamps, there are other clever ways to identify the differences. Be cognizant and sure you read the "GROSS DESCRIPTION" and if in doubt you just query your pathologist's okay.
I will assure you that I have been thanked more times than I can count on fingers and toes asking a pathologist's a question that something was missed. Their graciousness is so super kind.
They (pathologist's) work especially hard and deserve those RVU's. If they failed to do identify one from the other, it clearly may just be an innocent oversight. I would query them no doubt. Let them review it, they can do an addendum or amendment (depending on facility guidelines) to the pathology report if necessary to support billing two charges when appropriate of course.
I hope this assists you,
Please feel free to reach out if you have any additional questions or concerns okay.
Dana
 
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