Otolaryngology Coding Alert

Question: I am having an issue with some commercial payers when the surgeon removes more than one lesion.  I bill in RVU order with the lowest RVU being last (such as 12051, 11442-51, 11310-59).  They deny the closure, stating it is included in the 11310. We appeal and show in the dictation that the intermediate closure was not done on the 11310. They continue to deny the claim, citing CCI edits. What are we doing wrong?

Pennsylvania Subscriber 

Answer: Let’s start by looking at the codes you’re reporting: 

• 12051 – Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less 
• 11442 – Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm 
• 11310 – Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less. 

You’ve been correct to remember modifier 59 (Distinct procedural service), but you’ve been reporting it with the wrong procedure code. CCI edits list 12051 as a Column 2 code for 11310, but you can append a modifier and possibly be paid for both services. Append modifier 59 to 12051 instead of 11310 and resubmit the claim with documentation.