Wiki benign lip excision paid, intermediate repair denied.

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JesseL

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I coded 11440 and 12051 together and healthfirst NY denied 12051.

A lip lesion excision was done and intermediate repair was required.

They stated they denied the repair (12051) because it its column two of cpt (11440).

I see that is true on the NCCI edits but these two should be the correct codes for excision and intermediate repair of lip.

What do it do? :confused::confused::confused::confused:
 
Your coding seems correct, as per CPT guidelines "Local anesthesia is included in these services. These procedures include simple (non-layered) closure. If intermediate (layered) or complex closure is necessary, see 12051-12057 or 13131-13153. For excision of a malignant lesion of the face, ears, eyelid, nose, or lips, see 11640-11646. For destruction of premalignant lesions, by any method, including laser, see 17000-17004; cutaneous vascular proliferative lesions, see 17106-17108; benign, report 17110-17111. If a specimen is transported to an outside laboratory, report 99000 for handling or conveyance. Surgical trays, A4550, may be separately reimbursed by third-party payers. Check with the specific payer to determine coverage."

Just appeal and make sure that you have appended modifier 59 with 12051, as this pair has CCI conflict.
 
JesseL, you are correct that no modifier 59 should be added, as this would imply that the excision and repair were on separate lesions.

The reason for the CCI edit is that intermediate repair is bundled into benign excisions of 0.5 cm or less.

In a case such as this, I would recommend billing for the repair only. You are going to have to write off one or the other, and since the excision is the lower priced procedure, I would rather let that one be the wash.
 
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A co-worker pointed out that perhaps you can't choose which procedure to bill and which not to. Since the repair bundles into the excision, and not vice-versa, omitting the code for the excision in order to bill for the repair may be a form of upcoding.

I'm going to post this on the compliance forum and see what answers I get. I'll let you know. (Feel free to follow me over there in the meantime!) ;)
 
CatchTheWind said:
A co-worker pointed out that perhaps you can't choose which procedure to bill and which not to. Since the repair bundles into the excision, and not vice-versa, omitting the code for the excision in order to bill for the repair may be a form of upcoding.

I'm going to post this on the compliance forum and see what answers I get. I'll let you know. (Feel free to follow me over there in the meantime!) ;)
Click to expand...

Thank you :)
 
I've only noticed this now but there seems to be ncci edit conflict on all benign lesion excisions that are less than 0.5cm regardless of location with intermediate repairs.

Does CMS deem all benign lesions with less than 0.5cm do not require intermediate repairs?
 
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