# mutually exclusive



## Jamie Dezenzo (Oct 1, 2012)

Hello all,

11624 Chest
11604  Neck
12034 Chest repair
12044-59 Neck repair

Medicare still denied. Can not bill separate even though repair in different area?

Thanks
Jamie


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## mitchellde (Oct 1, 2012)

Yes you can bill when they are separate areas, what dx code did you use and what does the note state and what does the denial state?


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## Jamie Dezenzo (Oct 1, 2012)

Use 173.41 basal cell of neck

Denial reads This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Note: Refer to the 835 Healthcare Policy ID segment.


Thanks for your help!


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## mitchellde (Oct 1, 2012)

Is that the only dx code?  If so then perhaps that is your problem.  Or is it just the neck that is denying?  Or it is because your repair codes are so much larger than your excision codes.  Since the excision should equal the excised diameter then why is the repair code so much larger?


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## Jamie Dezenzo (Oct 1, 2012)

*op note*

Here is the op note: I didn't list all CPT codes prior.....

I billed

11644 173.31
11624 173.41
11604 173.51
12053 173.31
12034 173.51
12044-59 173.41

MCR paid all except the 12044

POSTOPERATIVE DIAGNOSES:  
1.	Basal cell carcinoma of the chest. 
2.	Basal cell carcinoma of the right neck. 
3.	Basal cell carcinoma of the right preauricular area.     

PROCEDURES PERFORMED:  
1.	Wide local excision of a 4 cm basal cell carcinoma of the chest with intermediate repair of an 8 cm acquired chest defect.
2.	Wide local excision of a right neck 4cm skin cancer with intermediate repair of an 8 cm acquired right neck defect. 
3.	Wide local excision of a 4 cm basal cell carcinoma of the right preauricular area with intermediate repair of a 7 cm acquired right preauricular area defect.   

ANESTHESIA:  Local.

COMPLICATIONS:  None.

INDICATIONS:  Patient was referred to my office after she had undergone excision of a chest and preauricular basal cell carcinoma.  On final pathology the margins were positive; therefore I have recommended reexcision with frozen section margin control.  In the office she was also noted to have a lesion on her right neck that was biopsied and proven to be basal cell carcinoma.  Therefore I have recommended this be excised at the same time.  

I have explained to her the risks and benefits of the procedure, including but not limited to bleeding, infection, scarring, facial nerve injury, spinal accessory nerve injury, recurrence of the lesion and need for additional procedures.  She has heard all this and is freely consenting to the procedure.          

PROCEDURE:  The patient was brought to the operating room and placed supine on the operating room table.  After adequate local anesthesia was achieved with 1% lidocaine with 1:100,000 epinephrine, the area was then prepped and draped in the normal sterile fashion. 

All of the lesions were marked with an appropriate margin.  _*They were then excised, starting with the chest region*_.  This was sent for frozen section analysis; the margins were noted to be free of tumor.  Therefore the flaps were widely undermined, the defect was then closed in layers using 4-0 Monocryl for the subcutaneous tissues followed by 5-0 plain gut for the skin.  

_*Attention was then turned towards the right neck*_.  This specimen was then excised, sent for frozen section margin analysis.  The margins were noted to be positive on the deep surface.  This was in the area between the sternocleidomastoid and the trapezius muscle in the area of level 5.  Therefore, the spinal accessory nerve was going to be vulnerable in this area.  An additional margin was taken from both cutaneous margins; also the deep tissue was then elevated off of the external jugular vein.  This was sent as a separate specimen.  Because the pathologist was having some technical difficulty, she asked that this be sent for permanent pathologic evaluation.  Following re-excision of the margin I did discuss this with her, and we will proceed in this fashion per her request.  The flaps were widely undermined.  The defect was then closed in layers using 4-0 Monocryl for the subcutaneous tissues followed by 5-0 plain gut for the skin.  

_*Attention was then turned towards the preauricular area*_.  The specimen was then excised down through the subcutaneous tissues.  The specimen was then sent for frozen section analysis.  The margins were noted to be positive anteriorly.  Re-excision of this anterior margin was performed.  The repeat frozen section analysis of the margins was clear in this area.  The flaps were then widely undermined.  The defect was then closed in layers using

4-0 Monocryl for the subcutaneous tissues followed by 5-0 plain gut for the skin.  Bacitracin was applied to this incision.  The other incisions were then dressed with Mastisol and brown micropore tape as an antitension dressing.  

Thanks again for taking a look!
Jamie


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