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Industry Insights

Another Round of Payment Denials with IHCs, 88341 and the Prostate G Codes

It seems our latest audit has caught a glitch in Medicare Immunohistochemistry (IHC) payments. We found that Cahaba GBA, which serves as the Medicare administrative contractor for Alabama, Georgia, and Tennessee, is denying claims for CPT code 88341 as multiples, using various denial codes:

MA15 – Your claim has been separated to expedite handling

M53 – Missing/incomplete/invalid days of units of service

M59 – Missing/incomplete/invalid “to” dates of service

MA130 – Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable.

This does not come as a shock or even as a surprise to me. It’s just another in a long line of instances where perfectly good claims are unpaid because the payers have not figured out the new CPT codes. This is exactly the same issue with new G codes that we saw last year.

Apparently, Cahaba has not caught up with the latest coding changes announced by Medicare in the 2015 Physician Fee Schedule (PFS) Final Rule, released five months ago on November 13, 2014.

As many of you know, Medicare eliminated 88343 for 2015, resurrected 88342, and introduced two new IHC codes:

88341: Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (list separately in addition to code for primary procedure)

88342: Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedures

88344: Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure

If you have been receiving denials for 88341, you will need to contact your Medicare Administrative Contractor (MAC) to ensure it has the most up-to-date coding and payment information from Medicare.

There have also been some recent issues regarding Medicare payment for the new prostate G code. In the final PFS for 2015, you may recall, Medicare killed two G codes (G0461 and G0462) that were new in 2014. Medicare replaced them with a single G code, G0416, to cover all prostate needle biopsies regardless of the number of biopsies submitted.

Despite these changes, we have found several large national payers denying the new prostate G code (G0416) as an HCPCS code. Their reasoning? This is an HCPCS code and therefore not payable to someone on the Medicare fee schedule.

So … all these claims have to be audited and refiled.  This means more work for less money.

Remember, it is a constant struggle to get paid; the payers and even Medicare seem to have a set of ever-changing rules as to when and if they are going to pay your claim.

Only the most diligent groups get paid completely. This means auditing and reviewing — and spending extra time and money — to recoup lost revenue.

To ensure you receive proper payment, be sure to follow up with MACs when you feel they have denied claims by mistake. And, do your due diligence when submitting to ensure you are submitting only clean claims.

Interested in learning more about the benefits of auditing or overall revenue cycle management? Contact us today for a free consultation.


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