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Medicare NCCI Policy Manual

  1. #1
    Location
    Everett, WA
    Posts
    10
    Question Medicare NCCI Policy Manual
    Medical Coding Books
    I recently read the updates and changes to the Pathology/Laboratory NCCI policy manual pertaining to 88342 (IHC) specimen vs. block quantity and prostate biopsy billing codes. Is anyone familiar with the new guidelines of billing specimens vs. blocks for 88342 and billing the G0416 for >5 prostate specimens? I'm particulary interesting in finding information/resources that pertain to whether or not the major commercial payers are following those specific guidelines. The information I received from the insurance companies are that they follow Column 1/Column 2 CCI edits, Mutually Exclusive edits, and Medically Unlikely Edits. They won't say whether they are following the guidlelines for specimen quantity and charge determinations. Any help would be much appreciated!

    Thank you
    Shawna Lumpkin, CPC
    Billing Office Manager/Pathology Coder

  2. #2
    Location
    Daytona Beach
    Posts
    30
    Default
    In response to the 88342 per block vs per antibody;
    Medicare has once again realigned with AMA guidelines. IHC is coded per antibody.
    Medicare's exception is with the "cocktail stains."

    A little history - In 2009, MCR policy deviated from AMA stating you could charge special stains and IHC per block if medically reasonable and necessary. In 2012, MCR realigned with AMA stating IHC is charged per antibody per specimen. In 2012, AMA guidelines updated Special stain descriptors - report one unit of special stain on each surgical pathology block, cytologic specimen, or hematologic smear.
    Kathleen Konkle, CPC

  3. #3
    Location
    Magic City - Birmingham, AL
    Posts
    20
    Default
    I, too am having difficulty with Prostate bx since the original HCPC was for the "saturation" biopsies and our clinicians were not performing them. Now it sounds like they are wanting all multi-site biopsies to be coded as saturation biopsies.

  4. #4
    Location
    Everett, WA
    Posts
    10
    Default Prostate G-Code
    Quote Originally Posted by ktr View Post
    I, too am having difficulty with Prostate bx since the original HCPC was for the "saturation" biopsies and our clinicians were not performing them. Now it sounds like they are wanting all multi-site biopsies to be coded as saturation biopsies.
    We made the decision to only bill this to Medicare and Medicaid directly since they follow NCCI policy and not all payers do. We are billing 88305 x quantity of specimens to all other payers unless we find that one follows the specific NCCI policy. Our major payers deny the G0416 as an experimental procedure since it is a saturation biopsy code. We'll see what happens.

    I hope that helps...thanks!
    Shawna Lumpkin, CPC
    Billing Office Manager/Pathology Coder

  5. #5
    Location
    Everett, WA
    Posts
    10
    Default
    Quote Originally Posted by kkonkle View Post
    In response to the 88342 per block vs per antibody;
    Medicare has once again realigned with AMA guidelines. IHC is coded per antibody.
    Medicare's exception is with the "cocktail stains."

    A little history - In 2009, MCR policy deviated from AMA stating you could charge special stains and IHC per block if medically reasonable and necessary. In 2012, MCR realigned with AMA stating IHC is charged per antibody per specimen. In 2012, AMA guidelines updated Special stain descriptors - report one unit of special stain on each surgical pathology block, cytologic specimen, or hematologic smear.
    Thank you for your input, that's very helpful!
    Shawna Lumpkin, CPC
    Billing Office Manager/Pathology Coder

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