Wiki help with cpt codes 21011 and 13132

[mercyolson]

Hello, our provider performs excision of tumor (21011) and the repair (13132 to 13151) at least 2X a week. I understand the repair code calls for a modifier 59 according to CCI edits. We have received denials from Humana, UHC and Healthnet for either the excision or the repair. Wondering if there is information you may have to avoid these denials. Any help will be greatly appreciated !
Mercy

 

[CodingKing]

The repair is inclusive. Just because modifier 59 can be attached with a code pair it does not mean you can automatically add it, it needs to meet criteria of distinct procedure. You cant just cut someone open and leave them that way so its part of the global surgical package.

CHAPTER III
SURGERY: INTEGUMENTARY SYSTEM
CPT CODES 10000-19999

L.9 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).

CHAPTER IV
SURGERY: MUSCULOSKELETAL SYSTEM
CPT CODES 20000-29999

I.30. Closure/repair of a surgical incision is included in the global surgical package. 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.