Wiki Denial CO-59

[Leann0523]

Denial for an office visit with a shave biopsy and destruction. Have the modifier on the 99213-25 and the modifier on the 11102-59 and ins denied the office visit with CO-59 Processed based on multiple or concurrent procedure rules. Refer to the 835 Healthcare Policy Identification segment (loop 2110 service payment info) pt has BCBS Medicare Advantage . Please help

 

[kdlberg]

If it was decided, after exam and assessment, to do the biopsy/destruction, the documentation should back this up and you can use that to resubmit. It needs to demonstrate that A to B to C thinking process.

If the patient came in for the biopsy, you can't bill 99213, because the related E/M services are included in the biopsy code.

My question is why is there a modifier -59? "Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances." There's not a second procedure here. Or did you also bill the 17000 for the destruction? This combination (11102 with 17000) is specifically addressed in the MLN Fact sheet: https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf