Wiki 40530 CCI edits

[NPSDEB]

My physician billed for 40530 and 13152 and when I ran it thru our scrubber it kicked out for CCI as bundled. So I look up 40530 (Resection of lip WITHOUT RECONSTRUCTION) and under the excludes it states Excludes reconstruction (13131-13153)??? I am confused! Please help. Thank you for any input.

 

[CodingKing]

Id just add modifier 59 to the repair code since its a column 2 code, modifier is allowed and CPT book tells you to bill it.

 

[NPSDEB]

Even though 59 states it has to be a separate incision/excision?

 

[thomas7331]

NCCI and CPT guidelines are not always the same - sometimes NCCI does not allow payment on a code that CPT tells you to report (use of operating microscope is a good example that I see often). It would not be appropriate add a modifier to unbundle the closure in this case. Generally under NCCI if a code is bundled, that tells you that the RVU value assigned to the procedure includes the work of the bundled code.

The following paragraph is from chapter 3 of the NCCI manual:

Closure/repair of a surgical incision is included in the global surgical package except as noted below. Wound repair CPT codes 12001-13153 should not be reported separately to describe closure of surgical incisions for procedures with global surgery indicators of 000, 010, 090, or MMM. Simple, intermediate, and complex wound repair codes may be reported with Mohs surgery (CPT codes 17311-17315). Intermediate and complex repair codes may be reported with excision of benign lesions (CPT codes 11401-11406, 11421-11426, 11441-11471) and excision of malignant lesions (CPT codes 11600-11646). Wound repair codes (CPT codes 12001-13153) should not be reported with excisions of benign lesions with an excised diameter of 0.5 cm or less (CPT codes 11400, 11420, 11440).

 

[NPSDEB]

Thank you Thomas!!

 

[CodingKing]

Thanks from me as well Thomas. I always have trouble when NCCI has modifier allowed, its so much easier when no modifier is allowed or Separate procedure is in the code description. Especially when NCCI is so off compared to CPT guidelines. I can understand operating microscope since its a piece of equipment that would normally be used with microsurgical techniques and the code shouldn't be required to specifically mention its use. When the CPT description (ignoring the parentheticals) specifically says something is not included that it should be able to be reported separately. I guess I can always write in to try to make a case for its deletion