Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for CPT code 88305. We decided that the Plan does not have to pay for
CPT code 88312. You asked the Plan to pay for CPT codes 88305 and 88312. You say that you would like the Plan to reconsider their denial of payment. The Plan says that the medical records do not support the billing of CPT codes 88305
and 88312. We decided that the Plan has to pay for CPT code 88305. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 88305 is Level IV - Surgical pathology, gross and microscopic examination Abortion -
spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for payment of CPT code 88305. Our reviewer says that the medical records support the billing of CPT code 88305. Our physician reviewer found pertinent to this review, the enrollee underwent endoscopic evaluation of GERD on 9/4/2019. Findings included: Schatzki ring, hiatal hernia, and 2cm benign-appearing antral polyp. A total of five pathology specimens were collected-- distal esophagus, GE junction, proximal stomach, distal stomach, and antral polyp. The provider was the reading pathologist. Pathology services were billed under CPT code 88305 (Level IV service). Based on the documentation, the provided pathology report supports Level IV service under CPT code 88305.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of payment for CPT code 88305 have been met. Therefore, we decided that the Plan has to pay for CPT code 88305. We also decided that the Plan does not have to pay for CPT code 88312. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 88312 is Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for payment of CPT code 88312. Our reviewer says that the medical records do not support the billing of CPT code 88312. Our physician reviewer found there is
no reason appreciated from available records to balance bill separately under CPT code 88312. The latter service was appropriately covered under the initial CPT code 88305 billing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of payment for CPT code 88312 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 88312.