Wiki Unbundle denial

[JesseL]

Patient had a malignant excision and repair done and also a benign destruction from a different site done. UHC denied the repair as "unbundled service."

I coded it this way

11602 (Paid)
12031-51 (denied)
17110-59-51 (Paid 50%)

Did I do something wrong? Planning to appeal this.

 

[maddisen]

Cpc, cgsc

12031 is bundled with 17110 so 12031 need modifier 59 appended.

 

[OCD_coder]

The 11602 only includes a simple closer as inclusive, so a modifier 51 should be correct per CPT Guidelines (See below). But, I have a note in my CPT book that UHC requires a mod-59. So I would apply the modifier 59 to both secondary codes 12031 AND 17110 for UHC only. A modifier 59 is only applied when NCCI edits are in effect. Due to 17110 bundling to 12031 and if the procedure was performed on the same anatomical site (including contiguous structure) it cannot be billed separately at the same surgical session. More information is really needed to confirm this code combination.

CPT Guidelines:
These services include simple (non-layered) repair of the skin and/or subcutaneous tissues. If intermediate repair involving layered closure of deeper subcutaneous or non-muscle fascia is required, it is reported separately with intermediate repair codes 12031-12037 or complex repair codes 13100-13122.

In addition, when sending in a Corrected Claim I would confirm that the diagnosis are linking appropriately since you have a malignant and a benign neoplasm this will support a clean claim. Multiple procedure reductions apply to the 2nd and 3rd CPT codes.

11602
12031-59
17110-59

*** Corrected information due to my typo.

 

[CatchTheWind]

OCD_coder, I think you meant 17110, not 11701; however, your advice seems to be correct (regarding 17110). DermCoder puts a 59 only on the 12031. (This surprised me, as almost everything you do along with a 17110 seems to need a 59! But not the 11602.)