# CPT code 21235/30465



## mercyolson  (Sep 14, 2015)

Hello everyone, BCBS Federal has denied on 2 separate occasions payment for these codes, stating "Documentation does not support the procedure".  I looked into the BCBS website to look for the specific verbage they are requesting, with no success.  Is there any place I can look for this information?  

Your help is greatly appreciated!

Mercy


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## Pam Brooks (Sep 15, 2015)

CPT assistant is the best source.  Unfortunately, it's licensed by the AMA, so it is not a free resource.  The book is published annually, or you can often get it online as part of an encoder product (such as Encoder Pro). Sometimes CMS will have payment policies that can point you in the right direction.


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## mercyolson  (Sep 17, 2015)

*21235/30465*

Thank you for your help, I purchased the CPT assistant.
Mercy


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## mercyolson  (Sep 17, 2015)

*Bundling 14040 and 11623*

Theses codes were denied for bundling.  According to  CCI edits, a modifier can be added.  It has been denied a second time. 

I would like to rebill without the repair code 11623, any thoughts?  

Mercy


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## jackjones62 (Sep 17, 2015)

If you read the guidelines for CPT 14040, this includes the excision of the lesion as well as the repair; was CPT 11623 and additional lesion that was removed? or you coded it as the lesion removal and the 14040 as the repair, if so you are unbundling, reread "Adjacent Tissue Transfer or Rearrangement" guidelines, it specifically states "the excision of a benign lesion (11400-11446) or a malignant lesion (11600-11646) is not separately reportable with codes 14000-14302".

Jennifer
CTENT


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## ljones88 (Oct 8, 2015)

Our office has run into issues with these two codes with many payers; BCBS, and UHC especially for the 30465. 

CPT code 21235: In order to bill this code with any ear surgery, the graft must be obtained from a seperate incision site. Meaning, if the incision is made postauricular, and the physician harvested the graft from the same incision site, CPT code 21235 cannot be billed. However, if the physician makes an incision postauricular in order to gain access to the mastoid cortex, and then creates an incision somewhere else on the patient's head or body to obtain the graft, then 21235 is supported and you can bill usually with a -59 modifier. It's not necessarily bundled by CPT but most payers bundle it. 

CPT code 30465: BCBS of Florida gave our group a hard time at first for 30465. BCBS was denying this code when billed with FESS codes, and SMRT codes because they believe that in order to gain access to other areas of the sinus, the vestibular stenosis had to be repaired and therefore it was inclusive to other procedures. However, we fought that continually by submitting appeals with op notes showing that the CPT descriptors for many FESS and SMRT codes did not include "repair of vestibular stenosis" in their description of service. Those we got overturned. Others denied for a policy exclussion under the Reconstructive/Cosmetic surgery guidelines with BCBS. Basically, if the 30465 was performed to restore appearances, they would deny the claim. We weren't doing cosmetic surgeries. We performed them for obvious medical reasons and would have to submit appeals on those showing how the surgery was medically necessary. BCBS of Florida requires medical review for 30465. I'm not sure how other states work but we normally have to submit all (literally all) prior records on file before determining if the service will be covered. Most of those we have had overturned successfully after appealing. 

In 2015 we billed 170 cases of 30465. To date, we are currently only appealing 10 of those denials still. So, appeal appeal appeal...They should pay if the documentation is there to support and the appeal letter is strong. I attached a copy of a sample appeal letter I've submitted in the past and has gotten my claims paid for 30465. It may take a little while to draft the letter but it can bring in the money that is due. I also attached the BCBS of FL and UHC Coverage Determination policy we have for 30465. You should be able to contact your provider rep or the insurance customer service dept to help navigate you to the insurance's coverage determination guidelines. If the rep you speak to cannot, ask for a supervisor. Insurance comapnies have to be willing to provide this info when requested.


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## mercyolson  (Oct 18, 2015)

Thank you very much for the United HC and BCBS information.  Since my last post we 've had 2 additional denials from BCBS for 21235.  Very frustrating !  

Mercy


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