# Help with modifiers/which procedure ranks first



## jamiejohnson63@earthlink.net (Jun 26, 2014)

I SENT TO MEDICARE 
11603
12032
17282 - 59
MEDICARE ONLY PAID 17282 - 59
HOW DO YOU KNOW WHICH PROCEDURE RANKS FIRST?
Thanks


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## Texascoder64 (Jun 26, 2014)

You put your codes in RVU order(highest allowable first) for this set of codes this is the correct order and check your CCI edits for appropriate modifier placement:
12032 -59
11603 - 51,59
17282-51       * some carriers do not require 51 /it is payer specific


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## OCD_coder (Jun 26, 2014)

I disagree a little bit with Texascoder with the placement of 11603 and 12032.

This is a tricky code combination to report on a claim due to the bundling issues and information you get from scrub-programs.  NCCI programs will direct the 11603 as a secondary listed code, but this would effect the payment too much as all three of these codes fall under the multiple procedure payment reduction rules.  

You should avoid at all costs putting a modifier 59 on a 1st listed procedure, they should always be on subsequent listed procedures for correct coding or column 2 codes.  Modifier 51 may be a carrier preference and it should be reviewed here as informational only.  The 17282 is included with the fee for the 11603 (bundles = modifier 59 is only needed on the lower CPT code, not BOTH) so it should only be reported if the documentation supports for the closure for the lesion performed as 12032 and placing a modifier 59 correctly separates both codes from the 11603.  A modifier on the 11603 is not only unnecessary but flags it for abuse, just be aware.

Lesion #1
11603 (RVU 2.82)  100% payment

Lesion #2
12032 (RVU 2.52) - modifier 59 (Bundles with 11603)  50% payment reduction
17282 (RVU 2.09) - modifier 51, 59 (Bundles with 11603) 50% payment reduction


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## CatchTheWind (Jun 26, 2014)

Texascoder64 is correct regarding the placement of the modifiers.  (Per the CCI edits, 11603 and 12032 both bundle with 17282, so they both require the 59 modifier.)

(Bundling is not based on RVUs.  That's why the 11603, which is the highest RVU procedure here, gets a -59, even though it will be paid at 100%.  In dermatology, we frequently see this phenomenon (higher RVU procedure gets bundled) when we bill code 17000.  For example, 11100 has a higher RVU than 17000, but gets bundled with the 17000.  So the 11100 takes the modifier 59, but the 17000 gets the 50% fee cut.)

Regarding the order in which the codes are listed, my understanding is that now that claims are processed electronically, carriers no longer require codes to be listed in RVU (or any other) order.  (If anyone has information indicating otherwise, I'd be interested in seeing it!)


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## CatchTheWind (Jun 30, 2014)

In case I wasn't clear, here's what I meant (and to simplify, I will put them in RVU order):
12032-59
11603-59
17282 

The 17282 "includes" the other two services, even though it does not have the highest value. (I know it makes no sense that an excision and repair would be "included" in a destruction, but this is the government's decision!) 

This is not a matter of opinion; it's in the CCI edits. (Check them and you'll see!) I also have verified them in Inga Ellzey's DermCoder.

If the payer requires you to add modifier 51 where appropriate, then here's how you would send it:
12032-59 (this gets 59 because it's bundled)
11603-51-59 (this gets 51 because it's less valuable and 59 because it's bundled)
17282-51 (this gets 51 because it's less valuable)

Regarding not having to put codes in RVU order, I don't have a source.  If anyone does, would love to see it.


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## mitchellde (Jun 30, 2014)

CatchTheWind said:


> In case I wasn't clear, here's what I meant (and to simplify, I will put them in RVU order):
> 12032-59
> 11603-59
> 17282
> ...


Totally agree!  You put the  modifier where it belongs and then list the codes in RVU order, you do not have to agree with the CCI logic, you just have to be able to deal with it.  And yes the first listed code can have a modifier.


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