Wiki Intermediate Repair Denial

[MichelleBursavich]

Provider billed 11400 for a benign excision of a cyst and billed 12031 for the intermediate repair. This is usually not an issue when billing our surgical procedures, but I have an insurance that is denying the repair (12031) as included in the payment for the excision. A 59 modifier was attached to the repair for unbundling. Any ideas as to why the insurance is including the repair in the excision? I know that the AMA description states that the intermediate and complex repairs are excluded from the excision and can be billed separately. Both the claim reconsideration and appeal were both denied as well.

 

[thomas7331]

NCCI rules differ from CPT instructions in this case in that the coding edits bundle all repairs to benign lesions that are less than 0.5 cm (the lesion excision codes ending in '0'): "Intermediate or complex repairs, adjacent tissue transfer, and grafts may be separately reportable if medically reasonable and necessary. However, excision of benign lesions with excised diameter of 0.5 cm or less (CPT codes 11400, 11420, 11440) includes simple, intermediate, or complex repairs which should not be reported separately." I assume that they have done this because it would be very unusual for a lesions of such a small size to require such an extensive closure and would not warrant the additional reimbursement.

 

[MichelleBursavich]

Thank you!

NCCI rules differ from CPT instructions in this case in that the coding edits bundle all repairs to benign lesions that are less than 0.5 cm (the lesion excision codes ending in '0'): "Intermediate or complex repairs, adjacent tissue transfer, and grafts may be separately reportable if medically reasonable and necessary. However, excision of benign lesions with excised diameter of 0.5 cm or less (CPT codes 11400, 11420, 11440) includes simple, intermediate, or complex repairs which should not be reported separately." I assume that they have done this because it would be very unusual for a lesions of such a small size to require such an extensive closure and would not warrant the additional reimbursement.

That makes sense. I will have to go back through and read that edit. Thank you.