Wiki Why Medicare deny 99212-25 & 11100 ??

[Orthocoderpgu]

Patient came in to have a skin lesion looked at. Physician looks at it and decides to take a biopsy. Billed:
99212-25
11100

Medicare denied the 99212-25 as having an invalid modifier and also denied the biopsy 11100 as being included in another procedure.

I used the -25 modifier to show that the decision to perform 11100 was made during the office visit and since 11100 has zero global, I used -25 instead of -57 modifier.

Does anyone have any idea of why Medicare is denying this? I can't find an LCD for 11100. Thanks for your help.

 

[LLovett]

Could be your Dx

Not sure who your carrier is, I pulled the LCD for Novitas LCD L27527 Removal of Benign or Premalignant Skin Lesions.

At the bottom it states

"3.Removal of certain benign skin lesions that do not pose a threat to health or function is considered cosmetic, and as such, are not covered by the Medicare program. Lesions in sensitive anatomical locations that are not creating problems do not qualify for removal coverage on the basis of location alone. If the beneficiary wishes one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The physician has the responsibility to notify the patient in advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is strongly advised that the beneficiary, by his or her signature, accept responsibility for payment. Charges should be clearly stated as well. Such claims billed to Medicare should append the –GY modifier to the CPT/HCPCS code billed. "

That would be my best guess why they are kicking it,

Laura, CPC, CPMA, CEMC