Wiki What Does Another Facilities Education Status Have To Do W/ An Independent Lab?

[SMatsu]

Help! We are appending the 26 modifier to thousands of claims b/c the facilities where the biopsy’s come from is supposedly an educational institution. I can’t find a single Medicare policy or guideline on this and neither the VP nor the RCM manager know why we’re doing this. 1/2 of the claims are going out w/ POS 11, which really doesn’t make sense to me.

The RCM manager is basing a lot of this on claims that deny for an overlapping out-patient stay and like much of the above, it doesn’t make sense. What does an overlapping out-patient stay have to do w/ a facilities supposed educational status?

 

[amyjph]

There is a lot going on here. There is not enough information to determine or advise.

1 - Is this an independent lab? Are you receiving specimens from outside facilities? “Independent Laboratory” - An independent laboratory is one that is independent both of an attending or consulting physician’s office and of a hospital that meets at least the requirements to qualify as an emergency hospital as defined in §1861(e) of the Social Security Act (the Act.) (See the Medicare Benefits Policy Manual, Chapter 15, for detailed discussion.)

https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c16.pdf

2 - Do the lab CPT being billed even have a PC/TC where modifier 26 would be appropriate? if they do, is the pathologist billing the 26? A modifier 26 *might* be appropriate in some cases.

3 - Does, "we are appending" mean the billing software is automatically doing this, or a person is manually doing it?

4 - What is your denial and rejection rate because if this is the case, do any claims go out coded and billed correctly the first time?

5 - Do you mean these are coming from teaching hospitals?

Here is an example policy with a reference section and helpful info: https://www.uhcprovider.com/content...rsement/MEDADV-Laboratory-Services-Policy.pdf

 

[SMatsu]

There is a lot going on here. There is not enough information to determine or advise.

1 - Is this an independent lab? Are you receiving specimens from outside facilities? “Independent Laboratory” - An independent laboratory is one that is independent both of an attending or consulting physician’s office and of a hospital that meets at least the requirements to qualify as an emergency hospital as defined in §1861(e) of the Social Security Act (the Act.) (See the Medicare Benefits Policy Manual, Chapter 15, for detailed discussion.)

https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c16.pdf

Yes, we are an independent laboratory, but we do not bill POS 81. We bill the POS where the biopsy was taken

2 - Do the lab CPT being billed even have a PC/TC where modifier 26 would be appropriate? if they do, is the pathologist billing the 26? A modifier 26 *might* be appropriate in some cases.

Yes, all CPT’s have a PC/TC. The pathologists work for our lab.

3 - Does, "we are appending" mean the billing software is automatically doing this, or a person is manually doing it?

Manually

4 - What is your denial and rejection rate because if this is the case, do any claims go out coded and billed correctly the first time?

We get denials for overlapping in/out patient stays occasionally, but never for a facilities educational status. That is an entirely different issue. The RCM manager isn’t obtaining the actual POS for each biopsy. They’re using a one size fits all based on a single call to the office.

5 - Do you mean these are coming from teaching hospitals?

In our system, the facility is tagged as either educational or non-educational. How do you know if it’s a teaching hospital and why would we append the 26 modifier if it were a teaching hospital?

Here is an example policy with a reference section and helpful info: https://www.uhcprovider.com/content...rsement/MEDADV-Laboratory-Services-Policy.pdf

Yep! I’ve read through that one as well as plenty others and I don’t see anything that justifies the 26 modifier other than in POS 19 or 22. Especially not in POS 11. If it’s POS 21, we bill the facility directly.

@amyjph Thank you for replying and any additional insight into this! I feel like we’re billing incorrectly and losing $.