Saturday, August 18, 2012

E” Code is Reported as the First Diagnosis and Procedure 88305 - correct way

procedure code description 

88305 Tissue exam by pathologist - $76


procedure  code 88305 describes level IV surgical pathology, gross and microscopic examination. When the operating provider or pathologist examines multiple, separate tissue samples on the same date of service for the same patient, the procedure code is reported using either multiple units or line items and may include any appropriate modifier(s). When the tissue samples are for prostate tissue, HCPCS lists procedure codes G0416-G0419 for 10 or more specimens in various increments for prostate needle biopsy. Therefore, the Health Plan will apply a frequency limit of nine units per date of service for procedure  code 88305 when reported with a prostate diagnosis. When procedure  code 88305 is reported in excess of nine units on the same date of service with a prostate diagnosis, the code will not be eligible for reimbursement.


Proper billing of procedure code 88305

Providers are incorrectly coding claims when billing for multiple specimens of procedure code 88305. Multiple specimens for the same date of service, billed on the same claim, should be submitted on one detail line by adjusting the “number billed field” (Units) to reflect the number of specimens. Billing these services on separate details is inappropriate.

Handling Form CMS-1500 Claims Where an ICD-9-CM “E” Code is Reported as  the First Diagnosis on the Claim

Provider Action Needed

This Change Request (CR) 7700 provides new instructions to return as unprocessable claims  submitted on the Form CMS-1500 where an ICD-9-CM "E" Code (external causes of injury  and poisoning) is reported as the first/principal diagnosis on the claim.

CR7700 will bring the policy for handling form CMS-1500 claims into alignment with the policy  for handling claims initially submitted in electronic format. The ICD-9-CM code set prohibits an  E” code from being reported as principal diagnosis (first-listed) on a claim. This guidance also  applies to V00-Y99 (external causes of morbidity) equivalent ICD-10 CM diagnosis codes. 

Therefore, if an “E” code or V00-Y99 range ICD-10 CM diagnosis code is the first listed  diagnosis code on the CMS-1500, the claim would not conform to the ICD-9-CM code set and electronic transmission of the electronic claim to a Coordination of Benefits Agreement  (COBA) trading partner would not be Health Insurance Portability and  Accountability Act (HIPAA) compliant.  

Claims initially submitted as electronic claims will, effective April 1, 2012, be rejected in  accordance with an edit established by CMS CR7596 when the principal (first) diagnosis code  presented in the diagnosis code field is an “E” code or, effective with the implementation of  ICD-10, when the principal (first) diagnosis is a code within the code range V00-Y99 of the  ICD-10- CM code set. This procedure will prevent those non-HIPAA compliant claims from  being adjudicated and then transmitted to the Coordination of Benefits Contractor (COBC) for  COBA crossover purposes. CR7700 applies this reasoning to claims submitted on CMS-1500  on or after January 1, 2013.

Be aware of the following:

• For claims received via form CMS-1500 on or after April January 1, 2013, Medicare  contractors will return as unprocessable claims for items or services where a  diagnosis code is required and the diagnosis code reported in the Number 1 field of  Item 21 of the Form CMS-1500 is an ICD-9-CM “E” code (external causes of injury  and poisoning) or, upon ICD-10 implementation, an ICD-10 CM code within the code  range of V00-Y99

• Reprocessed/adjustment claims failing these edits will be denied.

• Claims returned or denied as a result of these edits will show remittance advice  remarks code message MA63 (Missing/incomplete/invalid principal diagnosis) and  claim adjustment reason code 16 (Claim/service lacks information which is needed  for adjudication).

Billing Guide

Anthem Central Region bundles 88302, 88304, 88305, 88307 and 88309 as redundant/mutually exclusive with 88321, 88323 and 88325. Based on the Correct Coding Edits for Comprehensive Code 80000-89999; codes 88302, 88304, 88305, 88307 and 88309 are listed as component codes to codes 88321,88323, 88325. Based on procedure  Assistant article:

“Also included in codes 88311 through 88365 are three codes for consultation and report on material referred from another source (i.e., referred from another pathologist or facility). These codes are appropriate for use in reporting consultation provided to another pathologist in a different practice site or facility or in reporting consultations to another physician in the same facility/site on material referred from an outside source (e.g., review of slides from another restitution  prior to surgery or therapy at your facility 

• Code 88321 is used to report a consultation on a referred slide(s) from a specimen

• Code 88323 is used to report a consultation on a specimen when the consultant prepares a slide(s) for routine histologic staining 

• Code 88325 is used for a more comprehensive consultation on referred material that involves review of records and specimens


Therefore, when a pathologist is reviewing a specimen they are providing either the initial surgical pathology or acting as a consultant at the request of someone else. They cannot perform both services on the same specimen on the same date of service. If 88302, 883204, 88305, 88307 or 88309 is submitted with 88321, 88323 or 88325—only the consultation (88321, 88323 or 88325) reimburses.


The Identified Coding Problems 

During an audit of the procedure  codes associated with MMS across several states in a region, Medicare Recovery Auditors found instances in which the preparation and/or interpretation of the slides of tissue removed during the procedures was performed by someone other than the surgeon (or his/ her employee). Examples of findings from this audit follow:

• Example 1: A physician billed procedure  Code 17311 (Mohs Micrographic Surgery), while on the same date of service procedure  Code 88305 (Surgical Pathology, gross and microscopic examination) for the preparation and interpretation of the slides taken during the procedure, was separately billed for a specimen examination by a different practitioner without a modifier.procedure  Code 17311 was, therefore, an overpaid claim.


• Example 2: A physician billed procedure  Code 17313 (Mohs Micrographic Surgery) while on the same date of service procedure  Code 88305 (Surgical Pathology, gross and microscopic examination) for the preparation and interpretation of the slides during the procedure was separately billed for a specimen examination by a different practitioner without a modifier. procedure  Code 17313 was, therefore an overpaid claim.

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