Mulipule Excision- Malignant lesions

midnight1995

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Looking for so help -
Physician - is billing for 11606 3 times for excision
> right hand lesion 6mm, excision 4cm x 1.2cm
> Left Pretibial lesion 1cm, excision 2cm x 8cm
> Right calf lesion 1 cm, obligue excision of 2cm x 6 cm

billing:
11606
11606 (59)
11606(59)

per Medicare only allowed 2

Any help would be great.
thank you
Carolyn Lewis CPC, PCA
 

mitchellde

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From a procedure code stance you have indicated for malignant excision
11606
11606 59 ( if Medicare this should probably be XS)
11604 59 (again XS if Medicare)
The other question is what dx codes did you submit for these? You are required to have a path report to bill excisions.
 

ellzeycoding

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The medicare unlikely edits for 11606 = 2

Coding with modifier 76 is also acceptable for many carriers, rather than 59 for Medicare (because they aren't bundled together in the NCCI edits)...

You could bill as:

11606
11606 -76
11606 -76

Next, in box 19 of the paper or electronic claim, enter

"A total of three CPT 11606 were performed on 03/01/2017" (or whaver the DOS is).

You will most likely have to submit with notes to justify WHY you did more than the allowed MUEs of 2. Payment is not guaranteed for exceeding MUEs.

Note: Some carriers don't like modifier 76 on surgical procedures. Some also don't want 59 unless it appears as bundled pair in the NCC listings. Some want 59 instead of 76. It's very inconsistent.

Here is an FAQ from CMS

CMS


Q: How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit (MUE) value?

A: For MUEs that are adjudicated as claim line edits, each line of a claim is adjudicated separately against the MUE value for the code on that line. The appropriate use of HCPCS/Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value. CPT modifiers such as -76 (repeat procedure by same physician), -77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), -91 (repeat clinical diagnostic laboratory test), and -59 (distinct procedural service) will accomplish this purpose. Modifier -59 should be utilized only if no other modifier describes the service. For MUEs that are adjudicated as date of service edits, units of service (UOS) in excess of the MUE value may be paid during the appeal process. See separate FAQ for information about date of service MUEs.
 
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mitchellde

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76 is a modifier to be used for a procedure repeated on the same day in a different procedural session. To use it on a second excision at the same time as the first excision is inappropriate as the 76 will bypass the discounting edit and both procedure will pay at 100% when the second and subsequent procedures in the same session are to be discounted. the 59 is the modifier to indicate a separate site, however due to the overuse of the 59, Medicare created the "X" modifiers to be used when they are more descriptive.. The XS modifier indicates separate site and will be appropriate if the payer is Medicare or any other payer that is accepting the "X" modifiers.
in addition you only have two excisions that can be coded as 11606. the 4x1.2 is coded with the 11604.
 
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ellzeycoding

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Good catch on the size. I was focusing on the codes.

Most carriers accept 76 for repeat or "like" surgical procedures. This methodology has been taught by the American Academy of Dermatology for years as well.

Here are some sources of information from the AAD on the acceptable use of modifier 76…

Top-right of page 6…

https://www.aad.org/File%20Library/Main%20navigation/Practice%20tools/Coding%20resources/Derm%20Coding%20Consult/DCC_Fall-2014.pdf

Right-side or page 4…

https://www.aad.org/File%20Library/Main%20navigation/Member%20resources%20and%20programs/Publications/DCC/DCC_Spring_2015.pdf


Variances

Some carriers won't accept modifier 76 on surgical procedures, though. For repeat procedures when it cannot be billed in units, they say to bill without a modifer.

For example. here is WPS Medicare's policy on 76...

Most carriers also will take the multiple surgery reduction (modifier 51) without it being added and whether 76 (or 59/XS) is used on subsequent and repeat procedures.https://www.wpsgha.com/wps/portal/mac/site/claims/guides-and-resources/modifier-76

THis article also provide guidance on billing in excess of MUEs (use of Box 19).

For WPS Medicare, assuming three 11606s, you would bill without any modifiers (no 76 or 59/XS) and add the special instruction in Box 19.


Modifier 59 on same-code combinations or codes not appearing in the NCCI.

Many carriers will not accept modifier 59 on code combinations for "same code pairs" or code bundles not appearing in the NCCI tables.

Some carriers will. Again it varies.

Here is a presentation from Noridian in September 2016.

https://med.noridianmedicare.com/documents/10542/2840524/Modifier+59+Clarification+and+Changes+Presentation

Reference page 29...

Incorrect Use of Modifier 59
• Code combination is not in the NCCI manual
• Two same code combination

So in reality, the rules and applicaiton of 76 vs. 59/XS varies by carrier. There are so many deviations and variations in policies (even within the same state) that it's extremely difficult to say anything definitively or come up with a standard rule set the applies to all.
 
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