Question:
Pennsylvania Subscriber
Answer:
Although CPT states that you can bill for complex closure (13100-13160) in addition to the soft tissue tumor codes added in 2010, Medicare has stated that the excision/resection codes include simple, intermediate, and complex repairs. That means you'll need to bill these cases based on individual payer rules. CPT 2010 includes 72 new/revised 20000 level codes for soft tissue tumor excisions and resections that describe location, size, depth, and malignancy -- for instance, 21935 (Radical resection of tumor [e.g., malignant neoplasm], soft tissue of back or flank; less than 5 cm.).CPT 2010 instructions in the musculoskeletal system introduction state that closing the defect for some excisions "may require a complex repair, which should be reported separately."
Problem:
If you have a billing system that follows Medicare rules, it will not allow you to bill separately for a complex closure at the same site. But you should not report modifier 59 (Distinct procedural service) to any payers.Payer dictates solution: For Medicare, using modifier 59 indicates that the service is for a different site -- which it is not, in this scenario. Don't bill the complex closure for a soft tissue tumor excision to Medicare.
For a non-Medicare payer that allows billing according to the CPT rules, you can bill both the appropriate soft tissue and complex closure codes -- but you shouldn't append modifier 59 because no bundling issue exists.
Caveat:
You may need to add modifier 59 to work around your internal system so that it will allow you to bill a soft tissue tumor and complex closure together. Make sure you're following payer rules before you consider this solution.-- Technical and coding advice for You Be the Coder and Reader Questions provided by Pamela Biffle, CPC, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas.