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Medical Mutual of Ohio Denials on IHC

Posted by on Oct 21, 2014 in Latest News | Comments Off

By Jessica Jankowski, Executive Client Administrator

Once again we find another carrier creating a policy reflective of the Local Coverage Determination (LCD) that was published recently by WPS Medicare.

Medical Mutual of Ohio (MMO) created a policy effective July 2014 that tied the 88342 code to Lynch Syndrome tumor testing, thus requiring a prior authorization for any 88342 that comes through their door for processing.

While the 88342 is indeed one code that could be used in Lynch Syndrome testing, it is certainly not exclusive to this.  Once these denials were detected, we promptly connected with a representative from MMO to review some of our claims, inclusive of pathology reports, so that they could see how these 88342 codes were being utilized.

Roughly a month later, they rescinded the policy.  However, in order to get any claims paid, we needed to submit a “claims project” (fancy lingo for a spreadsheet with vital claim information) for MMO to reprocess the claims they originally denied.  We were informed by MMO that this would be the only way to ensure payment on these claims (Medical Mutual , 2014).


1). Pay close attention to your denials.  Is your biller providing you with detail of your denials monthly?  This is a great way to spot any denial trends.

2). Be sure your biller can trace back all claims that were denied AND provide reporting on payment for these claims to ensure the process has been complete.

Medical Mutual (2014, June ). Retrieved July 2014, from Medcal Mutual Medical Policies:

Codes G0461 & G0462 Denying in Error

Posted by on Oct 17, 2014 in Latest News | Comments Off

Denials caused by missed update to the Skilled Nursing Facility (SNF) consolidated billing code edit lists

By Ann Lambrix
Executive Client Administrator
Vachette Pathology

Yes folks, another issue with the G0461 and G0462 codes. Providers have seen denials for these codes stating “claim/service not covered by this payer/contractor.  You must send the claim/service to the correct/payer contractor, indicating the charges should go through SNF consolidated billing.”

Per CMS Part B MAC update:

NOTE:  Certain Healthcare Common Procedure Coding System (HCPCS) codes were not included in the 2014 annual update to the SNF consolidated billing code editing lists. A correction to the coding lists will be implemented in October, 2014. The affected HCPCS codes for practitioner billing are Q2050, (which will be added to File 1), and the professional component of G0461 and G0462 (which will be added to File 2). If you have claims with dates of service from January 1 through September 30, 2014, that have been erroneously denied, you should contact your Medicare Administrative Contractor to have the claims re-opened and re-processed.


Ann is the Executive Client Administrator at Vachette Pathology, your go-to source for auditing, practice management and industry updates and changes. Visit more of our news updates at or call us at 517.486.4262.


Cause for Concern with new BCBS of Georgia Provider Agreement

Posted by on Oct 1, 2014 in Latest News | Comments Off

It appears that Blue Cross Blue Shield of Georgia may be changing the rules without giving participating physicians fair advance notice.

The Medical Association of Georgia (MAG) has posted an article on its website alerting physicians that a new Blue Cross Blue Shield of Georgia (BCBSGA) provider agreement will automatically go into effect on November 15, 2014, replacing your existing agreement(s).

There is currently no indication of contractual changes on the BCBSGA website.

Our clients in Georgia have requested samples of the new contract(s) and fee schedule(s) for review, but there has been no response as of the printing of this letter.

MAG is indicating there are several points of concern, as the new contract(s):

  • Does not require a signature to be effective, even if the physician/practice hasn’t received formal notification from BCBSGA;
  • Allows BCBSGA to recoup money for claims that were incorrectly submitted by the physician/practice, offsetting payments without notifying the physician/practice beforehand;
  • Allows BCBSGA to change its Procedure Manual by making a “good faith effort,” whereas a signature was required in the past;
  • Removes a physician’s right to participate in a class action lawsuit against BCBSGA;
  • Changes the clause on termination without cause, extending it to six months.

If you currently participate with BCBSGA, we encourage you to contact your BCBSGA representative and inquire if this new contract and fee schedule will apply to your practice.

If so, request full copies of both for review, and don’t hesitate to ask for more time to evaluate before it takes effect.

If you have questions, please feel free to contact Vachette Pathology at 866.407.0763.  To keep updated on this and other current issues for pathologists, see our latest news or connect with me on LinkedIn.

WPS acknowledges error in Local Coverage Determination for IHC coding

Posted by on Sep 17, 2014 in Latest News | Comments Off

Recently, WPS providers in Jurisdiction J5 and J8 began receiving denials of Medical Necessity on G codes submitted to Medicare for IHC stains performed on or after 8/1/2014.  After further review, the culprit was identified…Local Coverage Determination (LCD)  #L33219.

Labeled “Molecular Diagnostic Testing”, this LCD erroneously linked the G0461 and G0462 as medically necessary ONLY for the following three conditions: V16.0 (family history of malignant neoplasm of gastrointestinal tract), V84.04 (genetic susceptibility to other malignant neoplasm of endometrium), and V84.09 (genetic susceptibility to other malignant neoplasm).

WPS will be issuing a revision to the LCD that will be posted to its website by Oct 1, as well as reprocessing claims that were inappropriately denied since August 1.  The mass reprocessing should take place around the end of September.

WPS Jurisdiction J5 and J8 is the Medicare Administrator for these following states:  Iowa, Kansas, Missouri, Nebraska, Michigan, and Indiana.

Ann Lambrix is the Executive Client Administrator at Vachette Pathology, your go-to source for industry updates and changes. Visit our website for at or call us at 517.486.4262.

Audit Finds Florida Medicaid Is Erroneously Denying Claims

Posted by on Sep 15, 2014 in Latest News | Comments Off

A recent billing audit we conducted for one of our clients led to a very serious finding that affects all pathology practices in Florida. We learned that several new 2014 CPT codes for immunohistochemistry stains (G0461, G0462 and 88343) are not listed on the 2014 Florida Medicaid fee schedule.

This is causing Florida Medicaid to erroneously deny claims when:

  • A combination stain is billed to Medicaid.
  • Florida Medicaid is secondary to Medicare or any other carrier that accepts G codes for IHC stains.
  • G codes for IHC stains are billed to Florida Medicaid instead of using 88342.

These codes should be available for use as described in the 2014 CPT and HCPCS books:

88342 – Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide

88343 – Each additional separately identifiable antibody per slide (list separately in addition to code from primary procedure)

G0461 – Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain

G0462 – Immunohistochemistry or immunocytochemistry, per specimen; each additional single or multiplex antibody stain (list separately in addition to code for primary procedure)

It is imperative that you audit claims for these codes and follow up on denials to ensure payment.

Vachette Pathology is an auditing and practice management firm working with practices in Florida and across the nation.  We are not a billing service — we make sure billing is done right.

For further information, contact Mick Raich at 866-407-0763 or  To keep updated on this and other current issues, read our latest news at or follow Mick Raich on LinkedIn.

Comparative Billing Report webinar on CBR201407 Immunohistochemistry and Special Stains hosted by eGlobalTech and Palmetto GBA

Posted by on Sep 12, 2014 in Latest News | Comments Off

Angela Granlund, Executive Client Administrator, Vachette Pathology

On Wednesday, August 27, 2014, CMS contractors eGlobalTech and Palmetto GBA hosted a webinar on CBR201407, a recent comparative billing report on Immunohistochemistry and Special Stains. A team from Vachette Pathology attended, including myself, and have the following to offer in summary.

Five thousand rendering pathologists, identified by National Provider Identifier (NPI), were chosen for this CBR.  Pathologists who did not receive this CBR did not meet the thresholds used to determine participation. These thresholds were not discussed or listed, however in the August G2 Compliance Advisor, the rationale given was simply because the participants’ billing patterns differed in some way from the national average of their peers.

The CBR focused on CPT codes 88305, 88312, 88313 and 88342, related specifically to esophageal and/or gastric biopsy specimens. Consultant cases were not included in this CBR.

The webinar began with a review of CPT coverage criteria: basics regarding policies of how and when to submit, medical necessity, billing protocols, etc.

The next topic covered was the methodology for determining the Average Allowed Charges per Episode of Care by CPT Code, the Average Allowed Services by CPT Code per Episode of Care, and the Percentage of Episodes with Special Stains.

  • Average Allowed Charges per Episode of Care by CPT Code:
    Determined by Total # Charges divided by Total # of Episodes for all CPT codes
  • Average Allowed Services by CPT Code per Episode of Care:

Determined by Total # Services for single CPT code divided by Total # Episodes with that CPT code

  • Percentage of Episodes with Special Stains:
    Determined using the counts of Episodes with at least one special stain

Unfortunately the webinar included no visuals, as the link to the slides was not provided until after it ended. Provider results were discussed using random examples, yet the slides could not be seen.

The provider results fell into one of four categories: Significantly Higher, Higher, Does Not Exceed or N/A.  The impression given, although not specifically stated, is that if you have codes with results that are Significantly Higher, that this is a “bad” thing.

In discussion with other attendees here in the Vachette office, we agreed this may not necessarily be so. There are at least two reasons providers may have higher results:

  • All data is related to the individual NPI, so whether the provider works for a hospital-based group or an independent lab or both does not seem to be taken into consideration for the comparison to state or national averages.
  • The results also do not seem to take into consideration if the provider works specifically with an endoscopy center and therefore may have higher results by default.

We also believe that this CBR is related to the article Palmetto GBA had on its website briefly which indicated that if you perform a high number of stains for gastric biopsies, then your practice would be looked at more closely.  We feel they will use this data to target providers for audit.

Takeaways for providers:  If you received a CBR, it is in your best interest to take the following steps:

  • Review all coding policies for IHC stains
  • Perform a coding audit on these types of cases to ensure they are indeed meeting these standards, and
  • Continue to follow eGlobalTech (the CMS contractor) for any future lab-related reports

A recording of the webinar is available for download at the link below, along with additional data on this CBR:

Webinar Recording:

CBR website:


Statistical Debriefing:


New Distinct Procedural Modifiers

Posted by on Sep 10, 2014 in Latest News | Comments Off

By Jessica Jankowski, Executive Client Administrator, Vachette Pathology

We all know or understand the basic idea of The Medicare National Correct Coding Initiative (NCCI), which establishes edits that are used to bundle service codes together.  The basis for this is to outline certain billing codes that cannot be billed with other codes, indicating codes that further define some portion of the first code.

The modifier -59 has always been a go-to modifier to indicate a second service code is indeed distinctly different or separate from the first service code. Per CMS’ recent MLN Matters published January 2014, this modifier “can be broadly applied,” and CMS believes that some providers will use this modifier “to bypass NCCI,” thus allowing for abuse and “high levels of manual audit activity” (MLN Matters Articles, 2014).

CMS is correct in their statement.  The -59 modifier has a broad realm for use, and can be used to identify different encounters, different anatomic sites, and distinct services.  Per CMS, the -59 modifier is seldom used properly, and therefore CMS will bring into play four new modifiers that will further define or describe the -59 modifier.  These will further be known as the –X modifiers (MLN Matters Articles, 2014).  The modifiers and their descriptions are listed below:

  • XE:  Separate Encounter.  A service that is distinct because it occurred during a separate encounter.
  • XS:  Separate Structure:  A service that is distinct because it was performed on a separate organ/structure.
  • XP:  Separate Practitioner:  A service that is distinct because it was performed by a different practitioner.
  • XU:  Unusual Non-Overlapping Service.  The use of a service that is distinct because it does not overlap usual components of the main service.

According to the MLN Matters, these modifiers will be used in place of -59 when appropriate.  Furthermore, CMS will still identify the -59 modifier when used; however, it is important to note that it is of great importance to use a more descriptive modifier when there is one available.  We may even see CMS require these –X modifiers on specific CPTs that they feel are at a higher risk for incorrect modifier usage.

Bottom line:  Understand these new modifiers and how they are used, and make sure your biller is aware of these and using them when appropriate.


MLN Matters Articles. (2014, 01). Retrieved 09 2014, from The Centers for Medicare and Medicaid Services :


Medically Unlikely Edits: Medicare Issues Updates July 2014 – How Will They Impact You?

Posted by on Sep 3, 2014 in Latest News | Comments Off

CMS has developed “Medically Unlikely Edits” to limit the maximum units of service a provider can report under most circumstances for a single beneficiary on a single date of service.

As announced in MLN SE1422, titled “Medically Unlikely Edits (MUE) and Bilateral Procedures,” for dates of service starting July 1, 2014, CMS is converting most MUEs into per day edits, with the MUE Adjudication Indicator (MAI) value indicating the type of and basis for the MUE.

CMS has defined three MAI values:

MAI of 1. MUE is based on a line edit and medically appropriate units of service in excess of the MUE. May be reported on a separate line with an appropriate modifier, and each line will process for payment.

MAI of 2. MUE is based on regulation or sub regulatory instructions.

MAI of 3. MUE is based on clinical information such as billing patterns, prescribing instructions, or other information, and exceptions beyond the MUE would be rare.

For example, IHCs: G0461 is limited to 9 units per date of service, whereas G0462 is limited to 60, with an MAI of 3.

Billers should be aware of these MUE edits and upon denial, review claim submissions and either request to reopen the claim for processing, or appeal with documentation to support excess units for medical necessity.

Ann Lambrix is the Executive Client Administrator at Vachette Business Services and Stark Medical Auditing, your go-to source for industry updates and changes. Visit our websites at and, or call us at 517.486.4262.


A Mid-Year Review of the Sample Impact Analysis for the 88342 / G0461 and Changes

Posted by on Aug 12, 2014 in Latest News | Comments Off

 Mick Raich, Vachette Pathology

Earlier this year I wrote a brief article on the changes with 88342 and the new G codes G0461 and G0462.  This article proved very insightful to me and many others.  It helped me understand how I was looking at things incorrectly, and it helped our client practices understand their revenue shortfalls.

It has been six months since that piece; let’s take a quick look back at the revenue losses we predicted, compared to actual loss.  Remember this is only for Medicare payments.

We reviewed a lab which bills globally and predicated a loss of $159,000.  Originally we figured their losses as of May 2014 would be about $16,611. In actuality, their loss is $16,248.  See the graph below.

global ihc tracking


For a group which bills professionally, we only predicted a loss of about $14,000 by May 2014.  In actuality the loss is $19,000.  See the graph below.

professional tracking

As you see with these two examples, most of our loss predictions were less than actual losses.  When tracking these things you have to be careful to look at date of service data and to look for claims that have already been fully adjudicated.

We find that many of our groups and their billers are still suffering from a bad process to handle these cases.

We have about 70 groups, labs and hospitals under contract, and we provided these projections to them last year.  Currently we are tracking losses for all our clients.  We are also aggressively auditing our clients each quarter to find missing and denied cases that have not been appealed.  There are millions of dollars left on the table in this area.

Here is exactly what you should do to track these cases and prevent these losses.

Sample IHC Auditing Process

1. Request cases from physician.

a. Request an appropriate number of pathology reports that have IHC CPT codes assigned. (Please note our groups are auditing ALL of their IHC cases.)

i. Dates of service should be at least six months prior to the audit start date.

ii. Reports should be randomly selected (the biller should NOT be involved in the selection process).

2. Receive initial cases from physician.

3. Send initial cases to biller requesting the following documentation:

a. HCFA form;

b. explanation of benefits from primary and secondary insurance with adjustment codes;

c. and patient transaction or history screen that shows payment and adjustment posting and current balance.

4. Receive initial case information from biller.

5. Match case information.

a. Attach the biller’s documentation to the pathology report received from the physician’s office.

b. Compare reported IHC CPT codes to billed CPT codes to confirm the correct CPT codes have been billed according to IHC guidelines.

c. Confirm correct number of units have been billed to carrier according to IHC guidelines.

d. Confirm correct IHC CPT codes were billed to Medicare or the insurance carrier according to insurance carrier guideline. (This is the hard part and where you must build a matrix to review each carrier.)

e. Confirm date of service to verify correct IHC CPT codes were billed to carrier per IHC guidelines.

f. Confirm insurance is allowing all units billed for IHC CPT codes.

g. Compile questions that require further explanation from biller.

6. Send initial questions to biller.

7. Receive question documents back from biller.

a. Review answers from biller and document case audit finding.

8. Complete case audit.

a. Categorize case audit findings and report in audit summary.

9. Perform payer analysis by EOB.

a. Confirm IHC CPT allowed amounts by insurance are being paid according to the managed care contract reimbursement language.

10. Track every case to payment or bad debt and zero balance

The best option is to audit your billing, then work forward.

I will release a final version of this comparison in February of 2015 to review actual dollars lost compared to our total predictions.

Although these types of predictions are not always 100% correct, it is important to at least considering your losses and be proactive.  For example, next you should be looking at the proposed CMS fee schedule for 2015 and building projections for those cuts.

If you have any questions please contact me, Mick Raich, at 866-407-0763 or 517-486-4262 or

Sequestration Frustration in Minnesota Impacts Pathology Revenue

Posted by on Jul 25, 2014 in Latest News | Comments Off

It appears Blue Cross and Blue Shield of Minnesota (BCBSMN) has made a significant error in Medicare reimbursements and has just recently realized it.

In May 2014, BCBSMN notified providers they will begin withholding a 2% Medicare payment reduction mandated by sequestration to all claims processed after June 6, 2014 — even though sequestration began April 1, 2013.

Plus, BCBSMN will be recovering the 2% reduction on Medicare claims with dates of service October 1, 2013, and later. However, they will only be targeting claims with a net payment of $100 or greater.

Sorry pathologists – their error is now your problem. Claim adjustments began the week of June 16, 2014. Look for your BCBSMN payment to decrease.

View the notification at:

As an auditing and practice management firm that works with pathology groups, laboratories and hospitals in Minnesota and across the nation, Vachette urges you to ensure your billing company is watching this, as well as verifying the 2% reduction in other Medicare Advantage plans.

If you have questions, please feel free to contact us at 866-407-0763.

Follow me, Vachette President Mick Raich, on LinkedIn to see more auditing updates.