Wiki New Biopsy with Destruction CCI Edits

[storme123]

actinic keratosis - destruction lesions, Billed 17000, 17003 x 4 L57.0, one punch biospy DX D48.5 cpt 11102 59, medicare is denying paying the 11102 but denying the 17000 and 17003 , 236 This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination,

We have always billed this way to Medicare and it paid, just started receiving these denials in the last 3-4 weeks.

Any ideas.

 

[arozance27]

You have the modifier on the wrong CPT. 11102 does not require modifier as it is the column 1 code.
17000 is the column 2 code per NCCI table and requires -59 modifier.

11102 17000 20190101 * 1 CPT Manual or CMS manual coding instructions

 

[angmoose]

Supporting documentation

You have the modifier on the wrong CPT. 11102 does not require modifier as it is the column 1 code.
17000 is the column 2 code per NCCI table and requires -59 modifier.

11102 17000 20190101 * 1 CPT Manual or CMS manual coding instructions

Do you have the link for this? We use the CCI site Craneware to verify and they state this:

CPT®/HCPCS Code 1[Find]DESTRUCT PREMALG LESION Info on CPT/HCPCS 17000

CPT®/HCPCS Code 2[Find]TANGNTL BX SKIN SINGLE LES Info on CPT/HCPCS 11102

Results for above billing combination...

National Correct Coding Initiative Edits
Effective April 1, 2012, CMS combined the Column 1 / Column 2 Correct Coding edit file and Mutually Exclusive edit file. All NCCI edits now appear in a single Column 1 / Column 2 Correct Coding table.

If a provider submits the two codes of an edit pair, the Column 1 code is eligible for payment and the Column 2 code is denied. There are a number of reasons why the edit pairs should not be reported together (e.g. one procedure may be considered a component of the other or the procedures cannot reasonably be performed at the same anatomic site - for full details see the latest NCCI Manual). However, if both codes are clinically appropriate and an appropriate NCCI-associated modifier is used, the codes in both columns are eligible for payment. Supporting documentation must be in the beneficiary's medical record.

Column 1 17000 Column 2 11102 Effective Date 01 Jan 2019 Acceptable with Modifier? Yes

 

[arozance27]

I pulled directly from the CMS NCCI table posted via the CMS website.
The table you are viewing via Craneware is incorrect.

Link: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html

 

[mitchellde]

Yes I too have to use the modifier on the 17000 per CCI edits. your software does appear to be incorrect. Also you cannot use D48.5 until the path report states it is a neoplasm of uncertain behavior, or calls it atypical. you will have use the L98.9 code or wait for path.