Wiki Lesion removal

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paula f3

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I am really perplexed with this one. Physican removed a benign lesion (8cm,thigh) w intermediate closure. I coded 11406, 12032. DX 216.7. Medicare pd the closure but not the excision due to medical necessity. We did a phone reopening added Dx code V49.89 and have still reced a denial. Called the surgeon office and they are telling me they used the same codes, sequencing different 12032, 11406-59. In cking my Medicare CCI edits neither of the 2 codes a bundles, BUT they got pd for both codes. Please explain so that I can understand .

Paula
 
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yes, I coded Dx 216.7 the first time claim was submitted and when I recd the denial, I added the V49.89
 
I agree with the surgeon's office coding...add the '59' modifier to the excision code... you have to do a medicare review, though
 
why would you use a modifier 59 though? I mean I'm in NJ & we use Highmark, we've never had a problem with this, maybe according to your LCD you may need it
 
also, I noticed that shouldn't the code be 12034 as you stated it was an excision of an 8cm thigh lesion? I would say you should check your Medicare LCD's & see if 216.7 is a covered ICD-9 code for the 11406, I can pretty much guarantee that's why it's denying to due medical necessity.

Just my thoughts!
Susan
 
I use the 59 modifier with Medicare...and I beleive that is the payer Paula is having problems with...I don't use it with commercial payers...
 
I do understand the concept that everyone is using the 59 modifier due to it being "Medicare".
I thought the 59 modifier is stating separate procedure....separate incision.
Wouldn't that make it wrong to add the 59 modifier just to get Medicare to pay....instead of the thought process that Medicare does not pay for closure as they do not pay for post-op office complications?

Tracy
 
You are all confusing me! The fact that he did an intermediate closure tells me that this lesion went deeper than just the skin

code 11046 is for removal of a lesion over 4.0 cm of the dermis only

the first thing i would do is query the doctor and determine how deep he had to excise the lesion dermis, subcutaneous, subfascial etc....

If it stayed in the just the dermis then 11406 is correct and the intermediate closure is separately payable per the cpt book notations under benign lesions, but you will have to check with your lcd's for your area in order to determine if diagnosis code is correct. Also did you bill what diagnosis the pathology report gave?
 
paula f3 said:
I am really perplexed with this one. Physican removed a benign lesion (8cm,thigh) w intermediate closure. I coded 11406, 12032. DX 216.7. Medicare pd the closure but not the excision due to medical necessity. We did a phone reopening added Dx code V49.89 and have still reced a denial. Called the surgeon office and they are telling me they used the same codes, sequencing different 12032, 11406-59. In cking my Medicare CCI edits neither of the 2 codes a bundles, BUT they got pd for both codes. Please explain so that I can understand .

Paula
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I think the previous post meant 11406 which is an excision code which is full thickness meaning thru the dermis into the subq tissue. So the intermediate closure is appropriate. I do not understand the rationale for the V49.89 it is code for other factors influencing health status and does not provide rationale for the closure. I also agree that you do not need the 59 modifier. It has always been a rule that an intermediate closure is separately payable. I would resubmit with the documentation and the instructions from the CPT book that state to code the closure in addition.
 
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