Wiki denails for debridement add ons 11046

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coder1

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Good Morning Coding world,

I recieved denails from MCR for the add on codes 11045-11047

The problem is that we bill for mulitple add on codes for a visit because the wounds are large in sq cms. MCR of MA and other states are denying our additonal add ons as duplicate because we use the same ICD 9 codes. When medicare was called, they said that in order to bill for additonal add on with the same DX codes we have to use 76 modifer. There is no publication on how to submit the DX codes with these add ons. I'm confused because what If there is only one LARGE wound debridement that in surface area requires additonal add ons. How do 76 modifier works?
 
It would help to see your op note. And FYI no you would not use the 76 modifier in this manner, that is for a repeated procedure in a different session. A debridement performed on a different area is not repeated. Can you supply the dx code used as well as all procedure codes and the op note?
 
wound care add ons

coder1 said:
Good Morning Coding world,

I recieved denails from MCR for the add on codes 11045-11047

The problem is that we bill for mulitple add on codes for a visit because the wounds are large in sq cms. MCR of MA and other states are denying our additonal add ons as duplicate because we use the same ICD 9 codes. When medicare was called, they said that in order to bill for additonal add on with the same DX codes we have to use 76 modifer. There is no publication on how to submit the DX codes with these add ons. I'm confused because what If there is only one LARGE wound debridement that in surface area requires additonal add ons. How do 76 modifier works?
Click to expand...

They may have been given a work around solution to share with providers until the edits are fixed. There were some notifications that the edits were not correct on the new codes and that they would not be corrected until April, so for the first quarter we billed correctly-say a 200cm debridement into muscle with a total surface as
11043 x 1
11046x9-this is all on one line, not listed 9 times-
and the system was denying 11046 as an MUE of 1 even though it states each additional 20sqcm! This is a system error and should be appealed until they get it corrected. You shouldn't change the dx codes because you are dealing with the same dx just reflecting the size of the wound with the add-on code.
We use CSNap to appeal them and they get paid on appeal until they very recently starting paying correctly through WPS.
 
MMAYCOCK said:
They may have been given a work around solution to share with providers until the edits are fixed. There were some notifications that the edits were not correct on the new codes and that they would not be corrected until April, so for the first quarter we billed correctly-say a 200cm debridement into muscle with a total surface as
11043 x 1
11046x9-this is all on one line, not listed 9 times-
and the system was denying 11046 as an MUE of 1 even though it states each additional 20sqcm! This is a system error and should be appealed until they get it corrected. You shouldn't change the dx codes because you are dealing with the same dx just reflecting the size of the wound with the add-on code.
We use CSNap to appeal them and they get paid on appeal until they very recently starting paying correctly through WPS.
Click to expand...

However 11046 in your example should be listed 9 times as it is each additional 20 sq cm, and it says to list separate. That is why the MUE is correct as the units should never be greater than 1 for a single line item. I read on the MCM website years back that units are to be used only for services that are quantity distributed such as timed services. Surgical services are not quantities they are each and each one is unique and distinc. So if it is denying for MUE due to units greater than 1 then that is a correct edit.
 
mitchellde said:
However 11046 in your example should be listed 9 times as it is each additional 20 sq cm, and it says to list separate. That is why the MUE is correct as the units should never be greater than 1 for a single line item. I read on the MCM website years back that units are to be used only for services that are quantity distributed such as timed services. Surgical services are not quantities they are each and each one is unique and distinc. So if it is denying for MUE due to units greater than 1 then that is a correct edit.
Click to expand...

Thank you, but our medicare contractor instructed us to bill as I noted. If the contractor in your state has a different bill method, by all means use it. I gave you an example of ours. Clearly if they are correcting the system, they must have intended that it be used as a quantity bill.
 
Just like the example from MMaycock its the same situtation besides I did bill the add on on seperate lines. The carrier told me 76, which I disagree totally. The problem I have is that every carrier from different states denied as duplicate but gave me different ways to bill. bill in units,use 76 modifier,etc. MMaycock could you let me know where you get the info for the edit error from WPS. I wish there was some clarification. The carriers are not helpful at this point.

Thanks,
Genova
 
The problem is a carrier is not to tell you how to bill a particular line item. They can be and most times are incorrect in what they tell you. The modifers and their meanings cannot be different from payer to payer. The definition of the 59 modifier fits for the additional line items of the code. However was the denial due to duplicate? and how did you have it listed on your claim?
 
Mitchelde,

ITS NOT A DUPLICATE, DENIAL IS INCORRECT

Its listed as 11043 7070570724
11046 7070570724
11046 7070570724

no modifiers


the 11043 and the 1st 11046 was paid

If its an appeal issue then I understand, but for every claim is crazy!!!!
 
Debridement

coder1 said:
Just like the example from MMaycock its the same situtation besides I did bill the add on on seperate lines. The carrier told me 76, which I disagree totally. The problem I have is that every carrier from different states denied as duplicate but gave me different ways to bill. bill in units,use 76 modifier,etc. MMaycock could you let me know where you get the info for the edit error from WPS. I wish there was some clarification. The carriers are not helpful at this point.

Thanks,
Genova
Click to expand...
I will try to find the transmittal- but I checked the CMS MUE list today and the add-on codes are not there. So they should not have a quantity edit.

You may want to try to bill it on 1 line as we do with WPS with a quantity of 9.

What I've noticed is that they often deny corrected claims as dupes unless you correct them on CSNAP. If you don't have access, it is free and it is awesome.

But moving forward, try your next batch with the quantity on one line and I'd love to hear how it works out.

Good luck!

Melanie
 
Thank you Melanie,


I also viewed the MUE Edits and notice the same thing. If you can find information that would be great!!!

For now, I will check for April claims across the board to see if it was just an edit error.

I appreciate the feedback , which is taken into consideration


Thanks,
Genova
 
We received denials on our add on debridement codes as well and I was told that the MUEs would be corrected effective April 1 and that we should refile these claims. So we did and now we have gotten the same denial again. Has this happened to anyone else?
 
coder1 said:
Mitchelde,

ITS NOT A DUPLICATE, DENIAL IS INCORRECT

Its listed as 11043 7070570724
11046 7070570724
11046 7070570724

no modifiers


the 11043 and the 1st 11046 was paid

If its an appeal issue then I understand, but for every claim is crazy!!!!
Click to expand...

The way you have it listed the system edits will pick up the second 11046 as a duplicate you do need a modifier to stop this just not a 76, you need the 59.
so it should be
11043
11046
11046 59
then you should have no problem with the MUE or the duplicate line item.
 
If the correct way to bill is
11043
11046
11046-59
then how do we bill when we come across a patient with a very large wound? I have seen patients with large wounds that were several hundred sq cm and I billed with multiple units and received pymt from commerical payers. However if I billed each add-on code on a separate line item I will run out of room.

Also according to our encoder, modifier -59 is not an approved modifier for 11046 for CMS.
 
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