Wiki 14040 denied


springfield, MO
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Medicaid has denied 14040 even after reading the note for this procedure. They say it needs to be recoded with the correct code. ?? 14040 is the only code billed for this procedure since the excision bundles with it. They have paid 14040 before and since, with almost the exact same documentation. The only difference on this one is the excision of the sesamoids. Not sure how that might affect it.
Any suggestions?

There was noted ulceration on the plantar aspect of the right first metatarsophalangeal joint. Using sharp dissection, the ulceration was completely excised from the area. There was noted too what appears to be sesamoids, which were also excised from the area. The area was fully flushed with sterile saline solution.

An incision was made on the plantar aspect of the 1st metatarsal neck area to create a flap which was then advanced dorsally, and it was trimmed to fit. Tourniquet was then released with total tourniquet time of 18 minutes. By using a #3-0 Polysorb suture, capsular structures were used to cover the distal stump of the right first metatarsal. Subcutaneous tissues were then reapproximated using #4-0 Polysorb in a horizontal mattress fashion and #4-0 & #3-0 nylon were used to reapproximate the skin ends.

Appreciate the help.
I think the issue is with the excision of the sesamoids. Although the intention was to address just the ulcer, once the ulceration was complete the surgeon then finds the sesamoids, which were then excised. There was no way to excise them without removing the tissue (and ulcer) first, so the excision of the sesamoids bumped up the procedure type into a higher degree of severity versus just an ulcer excision. The ulcer excision then basically became a component of the excision of the sesamoids. I'd say coding for the sesamoids excision is what MC is looking for.
Thank you for your reply,danskangel313.
What you're saying makes sense, but I was thinking the sesamoidectomy (speparate procedure) would bundle with the 14040?
I checked 28315 (assuming that's where you're headed) and there's no bundle with 14040. But 14040 isn't very specific so I don't know if that's the reason they don't bundle or if it's true that they really don't bundle. 28315 includes a layered closure, but nothing near the equivalent to a tissue transfer. In my opinion, the procedures aren't "separate" but rather, the 14040 is necessary to complete the 28315 procedure; in other words, both codes are both necessary to fully describe one procedure, rather than two completely separate procedures at the same site, but that's just my two cents.

I think the choices are to try billing them together and see what happens, or maybe billing just 28315 with a 22...?