Wiki Sending a pathology specimen to another lab

[acohn1986]

I hope I can ask this question correctly.

Example 1- The pathologist who works at a hospital receives a specimen 88305 and he gives his diagnosis. He may be uncertain or want another opinion so he sends it out to another facilty to be read. When we will this we bill for the physician, the 88305/26. When we send out to another facility we bill 88321 or 88323. We don't append a modifer on the 88321 or 88323. We are wondering if we should be adding some modifier....The insurance company is not accepting which ever charge they receive second and are denying it as inclusive to the previously billed charge. For example if they receive the bill for 88305 they are rejecting the 88321...Has anyone else had this problem?

Example 2- The lab received a specimen and sent it out to another facilty to be diagnosed. They billed 88305/26, 88313, 88346 and 88348. There were no other pathology charges billed for this date of service but it is being rejected and billing is saying it is similar to the previous situation....

Any help or thoughts would be appreciated.

 

[mrspicholas]

I'm not sure if I'm understanding your first example correctly. It's my knowledge that only the pathologist doing the consultation can charge the consult charge (88321, 88323), not the Dr. sending it out. The Dr. sending it out would only bill for his services which if I'm reading this right, would only be the 88305.

Did he receive the specimen for a consult and is sending out to another Dr. or is he doing the initial evaluation of the specimen?

 

[acohn1986]

Our doctor is doing the initial evaluation and then we send it out to for a second opinion. The institution we send the specimen out to bills us the 88321 and then we bill the patient.

 

[bbooks]

If you bill 88305 and 88321 (or 88323) on the same DOS, you need to put a 59 modifier on the 88305.

 

[atipton12]

I hope my opinion is not confusing:

If the pathologist you are billing for received the specimen and performed the gross examination, the microscopic examination and provided a diagnosis, it would qualify to bill a surgical pathology CPT code, 88305 according to your example. If the specimen is then sent to an outside lab for consultation, for a second opinion or specialized opinion (skin case sent to a dermatopathologist) the pathologist you are billing for does not bill for the consultation. Only the consulting lab (the dermatopathologist) would bill for the 88321 if they just review the submitted slides and provide a diagnosis. If the consulting lab (dermatopathologist) decides special stains are medically necessary to render a more specific diagnosis and are performed, they would then bill 88323 plus the charge for the special stains. The pathologist you are billing for will not bill for any additional work if he/she did not perform the work. However, if the outside lab just performed special stains, did not render a diagnosis, and the pathologist you are billing for read and interpreted the special stain results, they can then bill for the special stain charges as a professional component (with a modifier 26).

Now, if the pathologist you are billing for received slides from an outside lab for a consultation or specialized opinion, and the slides were reviewed by the pathologist you are billing for and diagnosis is rendered, the pathologist you are billing for may bill for 88321. In this case you are billing the insurance company for the consultation provided by the pathologist you are billing for. You will not bill for the surgical pathology codes. If the pathologist you are billing for deemed it was medically necessary to perform special stains and rendered a diagnosis of those stains, you will then bill for 88323 as well as the special stain charges.

Also, if the lab you are billing for received a specimen and submitted the specimen in its entirety to an outside lab for complete gross examination, microscopic examination and diagnosis, your lab will not bill for any charges. Your lab did not do any work as it was all submitted to an outside lab.

 

[lifewell2@comcast.net]

Regarding the last paragraph, could you please send me a link from the CMS guidelines

Regarding the last paragraph, could you please send me a link from the CMS guidelines? Thank you.

I hope my opinion is not confusing:

If the pathologist you are billing for received the specimen and performed the gross examination, the microscopic examination and provided a diagnosis, it would qualify to bill a surgical pathology CPT code, 88305 according to your example. If the specimen is then sent to an outside lab for consultation, for a second opinion or specialized opinion (skin case sent to a dermatopathologist) the pathologist you are billing for does not bill for the consultation. Only the consulting lab (the dermatopathologist) would bill for the 88321 if they just review the submitted slides and provide a diagnosis. If the consulting lab (dermatopathologist) decides special stains are medically necessary to render a more specific diagnosis and are performed, they would then bill 88323 plus the charge for the special stains. The pathologist you are billing for will not bill for any additional work if he/she did not perform the work. However, if the outside lab just performed special stains, did not render a diagnosis, and the pathologist you are billing for read and interpreted the special stain results, they can then bill for the special stain charges as a professional component (with a modifier 26).

Now, if the pathologist you are billing for received slides from an outside lab for a consultation or specialized opinion, and the slides were reviewed by the pathologist you are billing for and diagnosis is rendered, the pathologist you are billing for may bill for 88321. In this case you are billing the insurance company for the consultation provided by the pathologist you are billing for. You will not bill for the surgical pathology codes. If the pathologist you are billing for deemed it was medically necessary to perform special stains and rendered a diagnosis of those stains, you will then bill for 88323 as well as the special stain charges.

Also, if the lab you are billing for received a specimen and submitted the specimen in its entirety to an outside lab for complete gross examination, microscopic examination and diagnosis, your lab will not bill for any charges. Your lab did not do any work as it was all submitted to an outside lab.[/QUOTE]