If your lab has had claims denied for the technical component (TC) of pathology services and it believes they were incorrect, you may be right, and could avoid the costly, time-consuming appeal process. In a recent Center for Medicare and Medicaid Services (CMS) program transmittal (No. 1276, Change Request 8399 issued Aug. 9), CMS admits it has experienced “false positive” denials when the TC of pathology services provided to a hospital outpatient are billed on the same date of service as a hospital outpatient claim ordered by the same provider.CMS activated a common working file edit effective July 1, 2012, to prevent payment of the TC of pathology services after the expiration of legislative extensions that allowed some independent labs to bill Medicare directly for the TC of an inpatient or outpatient of a hospital (known as the grandfather clause). The edit did not take the place of service into account and inappropriately denied claims as a result.
Since activation of the edit, CMS contractors have experienced an increased volume of appeals when the TC of pathology services have been denied even though supporting documentation shows that the TC service provided had not been included in any hospital payments. The new criteria that allows payment going forward is a non-hospital place of service on the pathology TC claim.
The effective date of the CR, and the implementation of the corrections to the edit, is Jan. 6, 2014. Laboratories are on their own until then and should identify claims that are denied even though they have a non-hospital place of service. CMS contractors are not required, according to the CR, to identify and adjust previously denied claims although they may reprocess claims brought to their attention, no appeal required.
Copyright © 2013 Kennedy Information, LLC