Forum - Questions & Answers

Nov 15th, 2017 - npott1 9 

Pathology billing

Issue: There are four biopsies done on different locations on the same day, same patient, The physician decides he wants special staining on two of them and sends them to an outside lab. The other two he prepares and reads the slides himself. If the outside lab gets their claim in first, them mine denies as already paid to another provider. I have tried numerous modifiers to try to get the insurance co to understand, but nothing is working. Anybody have the same problem? Outside of having to appeal every single one of these situations, does anyone have a solution/success with this situation?

Dec 18th, 2017 - ChrisW   256  1 

re: Pathology billing

Consider billing your provider’s procedures as the first line items, and with the following modifiers:

1St Procedure (no Modifier)
2nd Procedure Bill with Modifier 51
3Rd Procedure Bill with Modifier 90
4th Procedure Bill with Modifiers 90 and 51

51 - Multiple procedures other than Evaluation & Management performed at same session, by same physician on the same patient on the same day
NOTE: Do not use modifier 51 with Add-on codes

90 - Reference (Outside) Laboratory:

The next issue is to avoid the appeal process, I suggest to wait until the labs are all back and submit them with your claim, this way the claims adjuster can see that there were actually 4 different tests being interpreted. The modifiers should help but this is a common denial when submitting the same code. You will find it faster and easier to send all of the appropriate information with your first claim to ensure reimbursement.

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