Otolaryngology Coding Alert

Question: We billed CPT® codes 12042 and 11420 with modifier 51.  I billed the 12042 as the primary procedure because it had a higher RVU and did not append a modifier (it was billable as not a simple closure). Insurance is denying it based on a modifier.  Any suggestions for how I should resubmit the claim?

West Virginia Subscriber

Answer: Coding edits bundle 12042 (Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm) and 11420 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less). The only time you can bill the codes together is when the physician performs the procedures in different anatomic sites and you have clear documentation. Even though 12042 has more RVUs than 11420, 12042 is the column 2 code in NCCI, which is a rare situation.  Assuming that the repair is a different site from the lesion excision, 12042 would be the primary procedure billed with modifier 59 (Distinct procedural service) appended and then 11420 would be billed as the second line on the claim.

If you try to report both codes for procedures to a single lesion, insurance will deny payment because simple closure is included in and you cannot bill an intermediate or complex repair for a lesion of 0.5 cm or less. Adding a 59 modifier to a closure to the same lesion that had been removed is improper use of the 59 and would be considered fraud since the 59 modifier cannot be supported as a separate site, separate encounter, separate physician, different procedure or surgery, separate incision/excision; separate lesion; or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.