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Novitas Solutions JL bundling of benign lesion of .5cm or less with closure

  1. #1
    Default Novitas Solutions JL bundling of benign lesion of .5cm or less with closure
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    Medicare is bundling excision of benign lesion .5cm or less with intermediate closure.

    Based on the CPT manual instructions that intermediate and complex closures should be reported separately, my physician wants to add a 59 modifier to the closure.

    It is my understanding that Medicare considers simple, intermediate and complex closure inclusive when the removal of the benign lesion is .5cm or less.
    The codes are NCCI edits and can be overridden by adding modifier 59 to the repair. Since the repair is not a separate encounter, separate structure, separate practitioner or unusual non-overlapping service, would modifier 59 really apply?

    CPT's 11440
    CPT's 12011, 12051, 13151

    Please advise.

    Camille Waterhouse, CPC

  2. #2
    You are correct on this and the CPT and NCCI guidelines sometimes do conflict. The language of the NCCI Policy Manual states that "excision of benign lesions with excised diameter of 0.5 cm or less (CPT codes 11400, 11420, 11440) includes simple, intermediate, or complex repairs which should not be reported separately. If more than one lesion is removed and one of those lesions is larger than 0.5 cm, an intermediate or complex repair may be reported, if performed, for a lesion larger than 0.5 cm. Removal of one lesion smaller than 0.5 cm does not preclude also reporting an intermediate or complex repair for a larger lesion."

    You can follow CPT guidelines and report the closure code if you wish, but a modifier 59 would not be supported in this situation where no other larger lesion was excised since, as you correctly point out, this is not separate encounter, structure, etc., and it will be denied by payers that follow NCCI. The use of the modifier solely to attempt to circumvent the NCCI reimbursement policy without other documentation to support it would be inappropriate.
    Last edited by thomas7331; 08-21-2018 at 06:19 AM.
    Thomas Field, CPC, CEMC

  3. #3
    Default Novitas Solutions JL bundling of benign lesion of .5cm or less with closure
    Thank you Thomas for your reply.

    I have been trying to locate documentation with a current date to support that Novitas Solutions JL is still not paying separate for the removal of benign lesions with a diameter of .5 cm or less and simple, intermediate and complex repairs.

    The last documentation that I can fine in print is from the Medicare Carriers Manual Part 3 Transmittal 1753 dated 5/17/2002. Do you know where I can locate documentation in print with a more current date? I have looked in the IOM 100-02, 100-03 and 100-04 without success.

    Thank you in advance for your assistance.

    Camille Waterhouse, CPC

  4. #4
    You will find it directly in the NCCI manual. It applies to all jurisdictions. Document is updated annually:


    Section E.6
    CRC (2018), CPC-P-A (2016), COC-A (2016), CPC-A (2015), PAHM (2010)
    Contract/Fee Specialist - Remote

    20 years health insurance experience: Audit, Claims, Customer Service, Payment Policy, Provider Relations, and Reimbursement

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