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Erroneous Denial of Pathology Claims

April 13, 2016

A claims processing issue has caused the following CPT-4 pathology codes to deny when billed without a modifier:

80163 80327 80341 80355 80369 81416 81460
80165 80328 80342 80356 80370 81417 81465
80300 80329 80343 80357 80371 81420 81470
80301 80330 80344 80358 80372 81425 81471
80302 80331 80345 80359 80373 81426 81519
80303 80332 80346 80360 80374 81427 83006
80304 80333 80347 80361 80375 81430 87505
80320 80334 80348 80362 80376 81431 87506
80321 80335 80349 80363 80377 81435 87507
80322 80336 80350 80364 81246 81436 87623
80323 80337 80351 80365 81288 81440 87624
80324 80338 80352 80366 81410 81445 87625
80325 80339 80353 80367 81411 81450 87806
80326 80340 80354 80368 81415 81455 89337

This issue is affecting claims submitted for dates of service on or after October 1, 2015.

These claims are receiving a Resubmission Turnaround Document (RTD) and are being denied with Remittance Advice Details (RAD) code 196: This procedure requires a modifier; modifier is not present.

Impacted providers do not need to take any action. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). Providers should continue to submit claims in a timely manner.

Providers are encouraged to check the Medi-Cal website regularly for updates regarding this issue.