Primary Care Coding Alert

Question: We billed a patient’s Wellcare Medicare Advantage Plan 11400-25, 17000, and +17003 for removal of a number of benign and premalignant lesions and were denied for the following: an issue with the 25 modifier on the 11400; an issue with billing 17000 by itself, or separately; and an issue with 17003 being billed on its own as an add-on code. What was wrong with this, and what do we need to do to put it right?

Codify Subscriber

Answer: The issue with billing 17000 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion) with the +17003 (… second through 14 lesions, each (List separately in addition to code for first lesion)) may be that you did not document the exact number of lesions destroyed. For example, if your physician destroyed six actinic keratoses, you could then report 17000 and +17003 x 5. And if they destroyed 15 or more lesions, you would report 17004 (…15 or more lesions).

More likely, the answer rests with the choice and placement of the modifier on the same claim with the 11400 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less).

The National Correct Coding Initiative (NCCI) bundles 17000 into 11400, but the modifier indicator for the pair is a 1, meaning that you may override the edit with an NCCI-associated modifier when appropriate. However, using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) would not be correct, because that modifier is only appended to an evaluation and management (E/M) service and not a surgical procedure such as a lesion excision.

Per Centers for Medicare & Medicaid Services (CMS) guidelines, “for surgical procedures, nonsurgical therapeutic procedures, or diagnostic procedures that are performed at different anatomic sites, are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI-associated modifiers” the correct modifier to append in this circumstance is modifier 59 (Distinct procedural service) (Source: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf). Additionally, you should append the modifier to the secondary (Column 2) code in the edit pair — to the 17000 rather than 11400.

However, you should check with your payer to see if modifier 59 is the best modifier to use in this case. CMS also goes on to note that a specific anatomic modifier, such as modifier RT (Right side) or LT (Left side) or another pair of anatomic modifiers, may be more appropriate than 59 in certain circumstances.