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U.S. hospitals recently received a letter from the Centers for Medicare & Medicaid Services (CMS), on behalf of Vice President Michael Pence, requesting they report their COVID-19-related data. This data request is two-fold. What Data Must Hospitals Report? First, the hospitals should report their data on COVID-19 testing performed in their Academic/University/Hospital ‘in-house’ laboratories, to […]
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Clinical diagnostic laboratories can identify specimen collection for COVID-19 testing using two new HCPCS Level II codes, effective March 1, 2020. Check Patient Location Before Coding Medicare posted these new specimen collection codes in a March 31, 2020, special edition MLN Connects and in a last-minute revision to the April 2020 HCPCS Level II quarterly […]
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UHC and Aetna are stating they will not pay for a TOB 141 through the hospital. Thoughts? Advice? Anything?
Thank you!
My experience has been that since the subscriber holds the relationship with the payer, they need to call to negotiate in network repricing. If they patient is unsuccessful then the provider can do an underpayment appeal on behalf of the member with UCR rates by calculating RBVS and an average of in network rates however because the provider appeals on behalf of the patient they forfeit being able to bill the patient at that point.
Also, when it comes to balance billing there are certain states that have laws against balance billing patients even in the event the provider is out of network.
I have also working for insurance companies processing claims and we would process any lab claims as in network if the ordering provider was in network but the lab was out of network. This was with BCBS so I am not sure if any other insurance companies will process the same way. Also, if the member is PPO member with BCBS they should get in network services anywhere they go.
I need resources and suggestions on how labs can successful obtain payment when out of network. It is very hard to compete with large lab corporations but there is also a need for smaller labs that specialize in particular lab tests. Also, the patient does not have a choice in where their labs are being sent so we want to help them as well and keep a good relationship with our clients.
Just wondering if any are receiving notices from Medicaid IL regarding the TC Modifier. I have never heard of using a TC modifier on a laboratory service before??? In what scenarios as a facility would you bill for the entire service? From a coding perspective, I am having a difficult time justifying using this on every Medicaid claim. I did look at the hospital manual and it looks like the verbage is reading as follows:
HFS L-210 (1)
L-210.1 Technical and Professional Components For any given lab test, no more than one provider may be reimbursed for the technical component of a service and no more than one provider may be reimbursed for the professional component. Practitioners billing the technical component only must use modifier TC. Practitioners billing the professional component only must use modifier 26. Both technical and professional components are implied when no modifier is entered.
=L-210.1.2 HFS 2360 Claim Form Revised June 2018
Hospitals frequently utilize reference laboratories (an off-site laboratory that completes the procedure on the specimen provided to them). If a reference laboratory has a financial agreement with a hospital to provide services for a hospital, then the hospital is entitled to bill the Department for both the professional and technical components of the service rendered at the lab for outpatient services. If no such financial agreement exists, the laboratory may submit charges to the Department.
Any thoughts on this??
Thank you,
Josie
I’ve asked the questions in a few different places on here and thought it would be better if all together to show the true picture. I’ve read all of the AAPC articles on the subject of 20610, so I’m familiar with when in diff joint etc, but there’s some confusion on joint and bursa in same general area. I’ve also read multiple threads on here and no absolute answer that I can locate.
Have a Dr billing insurance 20610 x 8 and J1040 x 8, as well as 89051 x4 and 89060 x4.
Here’s a breakdown of one of the scenarios:
Injection/Asp into RT shoulder w/ 45mg of NDC 00009028003
Injection/Asp into LT shoulder w/ 45mg of NDC 00009028003
Injection/Asp into RT subacromial bursa w/ 45mg of NDC 00009028003
Injection/Asp into LT subacromial bursa w/ 45mg of NDC 00009028003
Injection/Asp into RT hip w/ 45mg of NDC 00009028003
Injection/Asp into LT hip w/ 45mg of NDC 00009028003
Injection/Asp into RT trochanteric bursa w/ 45mg of NDC 00009028003
Injection/Asp into LT trochanteric bursa w/ 45mg of NDC 00009028003
Performs synovial fluid analysis for all areas mentioned with wbc provided and no crystals shown.
Questions:
1) Since bursae and shoulder/hip joints are technically different, does the above look correct? Or are they close enough to the joint that you only get the code (20610) once per joint space? CPT wording makes it look like you can get joint AND bursa, so I want to make sure that’s correct.
2) The NDC provided is for J1030, so should it actually be J1030 x9 instead of J1040 x 8?
3) Does 89051 x 4 and 89060 x 4 seem appropriate/accurate if notating wbc’s count and no crystals? (E.G. "LT hip: 5000 wbc and no crystals") Is this notation suffice?
Thank you all SO MUCH for any insight.
When are labs coded. For example, in profee coding for a well child visit, would you code 83655 and 85018 if they are done? I’m not talking about actual blood draws, but the actual labs performed on blood samples. I thought labs were only coded with a certain modifier and only if they were sent to outside facility (so the provider gets paid for transportation charges). Otherwise if they were performed by an internal lab, I thought the provider skipped coding them and the internal lab coded them? Can someone please summarize when to code labs for me? For profee and other kinds of coding too? Thanks!!