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Help please on lab charges

  1. #1
    Default Help please on lab charges
    Medical Coding Books
    Good Morning Everyone,

    I have a billing issue I hope someone could please shed some light on for me. We billed..
    99213
    81001
    85025
    80047
    36415

    DX 276.51, 276.9, 787.02

    Medicare paid all but the 85025 stating a modifier was missing. The billing rep placed a QW as modifier but it still came back denied. I believe a modifier is not needed and the DX supports the lab any help as to why this is being denied is greatly appreciated.

  2. Default
    What was the denial code

  3. #3
    Default
    stating a modifier was missing.

  4. #4
    Location
    Columbia, MO
    Posts
    12,531
    Default
    I believe it does need a qw if you performed these in house. If you sent them out to another lab, then are you paying the lab and billing the charges? If so then you need to indicate this on the 1500. If you are doing them in house then you need a qw modifier and you need the CLIA number on the claim form.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default Billing for Labs
    I am with a company that administers claims for self-funded employers. We have been seeing duplication of Lab and Path codes for same DOS, same provider, same patient coming in from both the outside lab and from the physician's office. Are their any limitations to what a physician's office can bill for labs that are performed outside the practice? Additionally, how should the provider indicate that they are using an outside agency on the 1500 especially if if some of the labs, are performed in the practice, and some hove to go out? How should they indicate that on the 1500? My concern is that the payer has been paying for both entities for the labwork. Does anyone have a best practice for billing 80047-80053 in the provider's office or can anyone direct me to a Medicare policy on this?
    Thank you for your feedback.

  6. #6
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default
    Quote Originally Posted by Jan S Plummer View Post
    I am with a company that administers claims for self-funded employers. We have been seeing duplication of Lab and Path codes for same DOS, same provider, same patient coming in from both the outside lab and from the physician's office. Are their any limitations to what a physician's office can bill for labs that are performed outside the practice? Additionally, how should the provider indicate that they are using an outside agency on the 1500 especially if if some of the labs, are performed in the practice, and some hove to go out? How should they indicate that on the 1500? My concern is that the payer has been paying for both entities for the labwork. Does anyone have a best practice for billing 80047-80053 in the provider's office or can anyone direct me to a Medicare policy on this?
    Thank you for your feedback.
    Jan, when the physician office bills for labs that are sent to an outside lab, they should first of all have a billing agreement with that lab; it will state that the lab will bill the physician's office for the tests, not the insurance company (except for Medicare/Medicaid - those need to be billed by the CLIA certified lab). Then, the physician's office should file the lab CPT codes to you (the ASO/TPA) with a 90 modifier, indicating that it went to an outside lab but they are billing for it. Those codes should be on a different CMS 1500 with the lab location in Box 32. For Medicare, there are only some labs that are CLIA-waived and can be filed by a physician's office with the QW modifier. When I worked for insurance, if we got claims for lab from both the physician (with the 90 modifier) and the lab, the second one received would deny as a duplicate, even with the modifier, so that we didn't pay for the lab twice. I remember telling Dr's offices that the lab had already billed - they usually weren't very happy!!
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

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