Reader Question: 'Grandfather Provision' Expiration Causes Headaches for Labs

Why This Topic Matters

It helps laboratories and pathology practices recognize that a denial may stem from Medicare place-of-service and payment structure issues rather than a simple claim-edit problem. That understanding can reduce wasted effort on incorrect billing fixes and direct the practice toward contractor communication and appeals.

Article Sections

1. Question

   The reader describes recurring Medicare denials for anatomic pathology claims after a change affecting technical component billing. The scenario involves a specimen from a physician office visit and a contractor denial tied to place of service.

2. Answer

   The response discusses the general reason the claim edit is not resolved by a modifier and frames the issue as one involving Medicare payment rules and place-of-service handling. It also notes the broader distinction between global pathology billing and technical component billing.

3. Heads up

   The closing note advises pathology providers to watch for similar denials and to work with their Medicare contractor when problems occur. It also mentions the need to pursue appeals until the issue is resolved.