Wiki Denial 11755 modifer issue Cross Posted

[LBernat7]

I also posted this in the modifier forum but here is the issue

patient was seen for a full skin with hx etc 99213 it was paid the second item on there was 11755 a bx of the nail it was denied for incorrect modifier using a 59. IBC the payor recommended taking off modifier we did that they denied that as well We called and appealed it to no help as they denied it again for incorrect modifier so the question is what modifier might they be looking for cause according to derm coder it is the 25 on ov and no 59 modifier or 25 on ov 59 on nail bx both of which have been denied.

Any help as to what modifier they may be looking for be great. We have submitted in past with no issues.

thanks

 

[CatchTheWind]

The 99213 gets modifier 25, and there is no modifier on the 11755. So the payer seems to be incorrect, and you'll have to escalate it to a higher level.

However, do be aware that 11755 can only be used if the provider cut down into the nail bed to do the biopsy. If he only clipped the nail, it's just part of the E/M.

 

[twizzle]

Modifier for 11755

The 99213 gets modifier 25, and there is no modifier on the 11755. So the payer seems to be incorrect, and you'll have to escalate it to a higher level.

However, do be aware that 11755 can only be used if the provider cut down into the nail bed to do the biopsy. If he only clipped the nail, it's just part of the E/M.

I posted my opinion a couple of days ago regarding the modifier required in the modifier section of this forum. No idea if it's correct but it seemed to be the only other option.

Agree with the documentation requirements for 11755. Clipping the nail does not meet those requirements.