Wiki 17000 denial

[MichelleBursavich]

Looking for help to see if anyone knows of NCCI edits that would justify this UHC denial or state otherwise that this CPT should be paid. Here's the scenario:

Patient presented for excision of a benign lesion on the right clavicle -- During the encounter for surgery, the patient had an unrelated concern of a scaly spot on the right side of the nose that was flaky and irritated. Physical exam showed a scaly erethemous papule (actinic keratosis) so the doctor destructed the lesion via cryotherapy.

The following was billed:
11402 (mod 59) - excision of benign lesion 1.1 to 2.0cm
12031 (mod 59) - intermediate repair 2.5 cm or less
17000 - premalignant lesion destruction

UHC paid 11402 & 12031 but denied CPT 17000 as [not covered when performed during the same session/date as a previously processed service for the patient]
I cannot find any NCCI edits that stated this service cannot be billed at the time of an excision or repair or another minor procedure. All appropriate modifiers were attached when claim processed and no major procedure codes were billed. Can anyone direct me to the edits that state this can or cannot be billed?? My reconsideration request was denied and I'd like to find documentation to support either an appeal or a provider write off.

Thanks!

 

[JesseL]

Looking for help to see if anyone knows of NCCI edits that would justify this UHC denial or state otherwise that this CPT should be paid. Here's the scenario:

Patient presented for excision of a benign lesion on the right clavicle -- During the encounter for surgery, the patient had an unrelated concern of a scaly spot on the right side of the nose that was flaky and irritated. Physical exam showed a scaly erethemous papule (actinic keratosis) so the doctor destructed the lesion via cryotherapy.

The following was billed:
11402 (mod 59) - excision of benign lesion 1.1 to 2.0cm
12031 (mod 59) - intermediate repair 2.5 cm or less
17000 - premalignant lesion destruction

UHC paid 11402 & 12031 but denied CPT 17000 as [not covered when performed during the same session/date as a previously processed service for the patient]
I cannot find any NCCI edits that stated this service cannot be billed at the time of an excision or repair or another minor procedure. All appropriate modifiers were attached when claim processed and no major procedure codes were billed. Can anyone direct me to the edits that state this can or cannot be billed?? My reconsideration request was denied and I'd like to find documentation to support either an appeal or a provider write off.

Thanks!

Just submit a corrected claim with modifier 59 on 17000. Sometimes payers have their own NCCI edit rules. You're just going to have to override it.

 

[AprilSueMadison]

Please don't append 59 just to append. Looking up NCCI edits and contacting payers to review their rules first is the proper thing to do.

17000 has a CCI conflict with 11402 and 12031. However, I do not see that there is a CCI conflict between 11402 and 12031. A correction that included the following may be needed to have this claim pay properly.

11402
12031
17000-59

I would also highly recommend creating a UHCOnline account. Once you do so, you can click on UnitedHealthcare Claim Estimator and can use their Professional Claim Bundling Logic page to check on the modifiers they may be expecting if your notes support the use. I've always found this incredibly helpful and I hope that you do so as well. Aetna, some BCBS sites, Humana and I think Cigna, all have CCI checkers on their websites.

 

[CatchTheWind]

April Sue, your advice is good, but you've got the 59 on the wrong code. (Per CCI, it goes on the 11402 & 12031.) However, in this case, that may be the way to get it paid!