Wiki Need Hand surgeon specialist billing assistance

[MMadrigal]

Doctor did a right index finger DIP joint ganglion Cyst removal and arthrotomy with osteophhyte removal distal phalanx.

I originally billed 26160 (727.41) and 26080 (715.14)

Private carrier denied 26080 stating services were included in 26160. When I read the Global Service data it specifically states removal of the osteophyte is not included in the 26160, so I then submitted a corrected claim for 26160 and 26989 (unlisted proc) with a copy of the Operative note and the GSD infomration.

The private carrier then paid the 26989, but they processed it as 26210, and then took back their payment for the 26160, stating it is included in the 26210.

Can any hand surgeon billers tell me the correct way to bill these two services? I did not use mod -59 as the there is only one incision, although he is removing 2 different lesions. ?? So frustrating. Mary

 

[dclark7]

The Global Service Data might not bundle these, but NCCI edits do. The Global Services Data is put out by the AAOS and most major carriers use NCCI edits which many times differ from CPT and specialty association guidelines. According to NCCI edits you can use a modifier to unbundle these two codes, but as you stated there is only one incision so 59 most likely would not be appropriate (can't say for sure without the op note).