Wiki Mohs, repairs, multiple code combo denials

[MichaelGA]

I'm new to Derm and I'm coming across a lot of denial issues. Examples below. Feedback appreciated!

13132-59 Claim paid
11200 Charge denied
Shouldn't both claims pay seeing that the 59 was added for the NCCI edit?


17311-79
17311-79-59 (BSC left mid-jawline and BSC left lateral jawline//2 separate dx codes)
17312
14301-79
14302-79
Should 2 units of 17311 be billed instead of separate line items? 14302 and 17312 are the only charges that paid. How can the add-on be paid and not the parent code? This is GA Medicare.


21235 billed with 14061. Graft pays, flap denied.

 

[CatchTheWind]

In the first case, 11200 may have been denied because it is not a covered service, and they mistakenly allowed the repair because their computer did not recognize the fact that the repair was of a non-covered procedure. (By the way, are you sure that a complex repair really was performed? For a skin tag removal??? That doesn't sound right!)

In the second case, the second Mohs should have modifier 76, not 59. Other than that, it all should have paid (assuming medical necessity was met), so you'll have to ask the payer why they denied.

In the third case, if the graft was from skin that is not attached to the flap, they should both be payable. You may need to appeal with records.

 

[m.edwards]

For the first one, depending on what other codes are being billed, the modifier 59 is appropriately appended to the closure to override the NCCI edit on that 11200-13132 edit pair. Was there another surgical code billed that coincides with the closure?

For the second case, When multiple lesions are being done during the same session, you code each one separately with modifier 59 on the subsequent sites, and not modifier 76 as it is not a repeat procedure, but rather a separate anatomical site. 17312 should not be paid if the parent code is denied, so that is odd, I would agree. Sometimes the order of modifiers affects the outcome of the claim (i.e. list payment modifiers first before information ones), however, both 79 and 59 and payment modifiers, and it makes sense to use 79 first. Appeal/reconsideration may be warranted as this appears clean.

21235 and 14061 have no NCCI edit pair that I can find, so it may be worth an inquiry to get more information around the denial.