Otolaryngology Coding Alert

Question: We’ve submitted two claims for 21012 performed in our office (for two different patients). One claim was paid but the other was denied because the procedure “cannot be performed in an office setting.” Why is that? Is there any way to get payment for it in the office setting?

New Mexico Subscriber

Answer: According to CMS, code 21012 (Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater) has a 90-day global period.

You don’t indicate whether the two claims are from the same payer or from two different payers, or whether they involve Medicare or a non-Medicare insurer. Compare the details of the two claims to see what might be different. For example, the one that was paid might be for a commercial insurer while the denial might have been for Medicare or Medicaid. If there’s no difference between payers, check the insurer’s LCDs (local coverage determinations) to verify the payer’s position on the procedure. Collect all your documentation and prepare an appeal if you believe it’s appropriate.