Wiki Head and neck lesion excisions, Medicare denied.

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JesseL

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Dr performed two benign excisions on neck and scalp. The problem with this is they both use the same CPT codes, 11421, and they're both within the same size range so I have to use this code. A repair was also done, coded the repair based on the two repair sizes combined, I believe that's the rule, please correct me if I'm wrong.

I coded it as below:
11421-59-51 ---> Denied as "duplicate claim/service"
11421-59-51 ---> Paid 50%
12042 ----------> Paid 100%

Did I coded incorrectly? Do I need to submit a corrected claim or appeal?

Help appreciated.
 
I agree with the modifiers on the 2 excisions but am wondering why you would add the repairs together as they are in different anatomical areas. The scalp should be coded with the 12031 and the neck with the 12041 categories.
 
Hello,
Medicare Bulletins posted towards the end of last year that Medicare would no longer be accepting modifier 59 for multiple procedures of the same code. You need to use modifier 79. I'll see if I can locate he bulletin and post it on here for you.
 
you cannot use a 76 for a procedure performed in a separate location on the same day. That goes contrary to the definition of the 76 modifier as stated in the federal register.
 
lindaj0317 said:
I agree with the modifiers on the 2 excisions but am wondering why you would add the repairs together as they are in different anatomical areas. The scalp should be coded with the 12031 and the neck with the 12041 categories.
Click to expand...

I didn't catch that... DARN...
 
"lindaj0317" is correct that you need two repair codes: scalp is #12031 and neck is #12041.

"jholt12" is correct about using modifier 76 rather than 59.

Per the Ellzey DermCoder, here is the correct way to code this: (Omit the 51 modifier if your carrier does not require it.)

12042
12031-51
11421-51
11421-51-76
 
CatchTheWind said:
"lindaj0317" is correct that you need two repair codes: scalp is #12031 and neck is #12041.

"jholt12" is correct about using modifier 76 rather than 59.

Per the Ellzey DermCoder, here is the correct way to code this: (Omit the 51 modifier if your carrier does not require it.)

12042
12031-51
11421-51
11421-51-76
Click to expand...
I agree on the two separate repair codes however 76 is not the correct modifier. 76 per the federal register definition as well as the AMA definition, id for the exact same procedure repeated in a different session. The 76 modifier will allow incorrect payment as it bypasses the multiple procedure discount. When you have two procedures in the same session that need to be unbundled due to separate site or incision the 59 is the only appropriate modifier. it will allow the second procedure to discount as it is suppose to.
 
i cannot locate the bulletin but i have been denied when billing the same cpt code with the same diagnosis. in the past i added a mod 59 and was paid on the second excision however i was denied again so i called and changed the quantity to 2 and was paid. not sure where this is documented but i have had this happen on 3 different claims this year.
 
i called novitas and per the rep when billing 2 or more of the same code with the same diagnosis or different diagnosis' it is recommended that we bill with a quantity. this has never been the case before and there is no bulletin in place.
 
CatchTheWind said:
"lindaj0317" is correct that you need two repair codes: scalp is #12031 and neck is #12041.

"jholt12" is correct about using modifier 76 rather than 59.

Per the Ellzey DermCoder, here is the correct way to code this: (Omit the 51 modifier if your carrier does not require it.)

12042
12031-51
11421-51
11421-51-76
Click to expand...

I've been coding Derm for almost 18 years, and I am in full agreement with this one.
 
Regarding the permissibility of using modifier 76 for different lesions (as opposed to its use being limited only to a repeat procedure on the same lesion), I just came across this from the MAC for Alabama, George, and Tennessee at www.cahabagba.com/documents/2013/07/modifier-59-session-mod.pdf‎ . This apparently is a Q&A following a webinar presented by the MAC:

Q: When billing lesions with the same procedure code, is the 76 modifier appropriate?

A: Yes, it is appropriate to use modifier 76 on surgical services when the same procedure is performed more than once per day and there is not an anatomical modifier that can be utilized.

Another questioner goes on to state: "You mentioned that modifier 76 is not limited to the same site"... (and then asks a question about billing in units).

My understanding is that modifier rules are set by CMS, not the individual MACs; therefore, this should serve as proof that modifier 76 can be used when two different procedures with the same CPT code are performed on the same day.
 
CatchTheWind said:
Regarding the permissibility of using modifier 76 for different lesions (as opposed to its use being limited only to a repeat procedure on the same lesion), I just came across this from the MAC for Alabama, George, and Tennessee at www.cahabagba.com/documents/2013/07/modifier-59-session-mod.pdf‎ . This apparently is a Q&A following a webinar presented by the MAC:

Q: When billing lesions with the same procedure code, is the 76 modifier appropriate?

A: Yes, it is appropriate to use modifier 76 on surgical services when the same procedure is performed more than once per day and there is not an anatomical modifier that can be utilized.

Another questioner goes on to state: "You mentioned that modifier 76 is not limited to the same site"... (and then asks a question about billing in units).

My understanding is that modifier rules are set by CMS, not the individual MACs; therefore, this should serve as proof that modifier 76 can be used when two different procedures with the same CPT code are performed on the same day.
Click to expand...

": Yes, it is appropriate to use modifier 76 on surgical services when the same procedure is performed more than once per day and there is not an anatomical modifier that can be utilized."
The same procedure performed more than once per day, does not mean a procedure performed at different locations, the same procedure performed more that once is exactly that the same exact procedure, a procedure performed in two different locations, while it may be the same code they are two different procedures. The 76 modifier is more commonly use for repeat EKGs or repeat xrays.
I know this is commonly interpreted as the same code used twice but that is incorrect as the 59 modifier is clearly the correct modifier for this and there are two modifiers that can be used for the same purpose, as that would defeat the purpose of the different modifiers.
I know many will disagree.
 
I have to respectfully disagree with your interpretation, as this MAC's Q/A makes it very clear that they are referring to two different lesions.

First, note that the question was "When billing lesions with the same procedure code...." No one could possibly argue that this is referring to a repeat procedure on the same lesion.

Second, the next questioner quotes the presenter as having said "that modifier 76 is not limited to the same site" and the answer accepts this as accurate.
 
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