11042 denying

[footandankle2075@gmail.com]

Medicare Indiana constantly denies 11042 for patient who are seen weekly or after. Can someone help me code it properly with modifier to get the code paid. These are patients that comes to have ulcer debrided by the doctors.

Am I missing something?? i have used mod 59,79 even 58 to get the code paid but denies for "not deemed medical necessity". Please Help!!

 

[iowagirl77]

If it has been denying as not medically necessary, that is not likely due to a modifier. Have you reviewed the LCD to make sure the diagnosis you have linked to it is covered and that it fits any other requirements outlined in the LCD?

 

[csperoni]

I agree - look to the diagnosis. 11042 does not have any global days, so modifiers indicating it was outside the global package do not apply. Unless of course, the patient had a separate surgery prior.

 

[mitchellde]

I agree it must be your dx code.. what code are you using.. what is the patient condition that requires daily debridements.

 

[cgaston]

The add-on codes 11045, 11046 & 11047 have maximum daily units of either 8 or 10 units for Medicare (it's been a while since I coded debridements).

We used to appeal the denial with a copy of the operative note asking that they waive the maximum unit stating the report verifies that the physician performed a large scale debridement and s/he should be reimbursed for his/her work.



ETA: Nevermind! I just realized your denial is for 11042. I agree with mitchellde that it must be you diagnosis code then.