Otolaryngology Coding Alert

Question: I submitted a claim for 11100 and 11101-59, but the insurance denied it. What did I do wrong?

Pennsylvania Subscriber

Answer: The insurance denied the claim because +CPT 11101 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; each separate/ additional lesion [List separately in addition to code for primary procedure]) is an add-on code, meaning you should not report it with a modifier. You should report add-on codes with a main code, to denote services extending beyond the primary code. In this case, you'll use 11101 for a second or subsequent biopsy(s).

Suppose your otolaryngologist performed a complex flap reconstructive procedure that you know you should report with 14301 (Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm). Now suppose the size of the reconstruction effort was much larger than the measurements denoted in 14301's descriptor.

That means you should report one or more units of addon code +14302 (... each additional 30.0 sq cm, or part thereof [List separately in addition to code for primary procedure]) in addition to 14301. Because these are addon codes, not only do you not use modifiers, but your reimbursement won't suffer any multiple surgery discounts. Here's another example. Suppose the patient undergoes Mohs chemosurgery. You'll report 17311 (Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation ...) with +17312 (...each additional stage after the first stage, up to 5 tissue blocks [list separately in addition to code for primary procedure]), if your physician denotes an additional stage with up to five tissue blocks. You will not apply a modifier to 17312.