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Lesion removal

  1. Default Lesion removal
    Clearnace Sale
    I am really perplexed with this one. Physican removed a benign lesion (8cm,thigh) w intermediate closure. I coded 11406, 12032. DX 216.7. Medicare pd the closure but not the excision due to medical necessity. We did a phone reopening added Dx code V49.89 and have still reced a denial. Called the surgeon office and they are telling me they used the same codes, sequencing different 12032, 11406-59. In cking my Medicare CCI edits neither of the 2 codes a bundles, BUT they got pd for both codes. Please explain so that I can understand .

    Last edited by paula f3; 03-05-2010 at 12:43 PM.

  2. #2
    Kansas City, MO
    you didnt say what dx they you know??
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

  3. Default
    yes, I coded Dx 216.7 the first time claim was submitted and when I recd the denial, I added the V49.89

  4. Default
    what DX did The surgeon's ofc use not what you used?

  5. #5
    I agree with the surgeon's office coding...add the '59' modifier to the excision code... you have to do a medicare review, though

  6. Default
    why would you use a modifier 59 though? I mean I'm in NJ & we use Highmark, we've never had a problem with this, maybe according to your LCD you may need it

  7. Wink
    also, I noticed that shouldn't the code be 12034 as you stated it was an excision of an 8cm thigh lesion? I would say you should check your Medicare LCD's & see if 216.7 is a covered ICD-9 code for the 11406, I can pretty much guarantee that's why it's denying to due medical necessity.

    Just my thoughts!

  8. #8
    I just use the '59' modifier for medicare not for commercial insurance.

  9. #9
    I use the 59 modifier with Medicare...and I beleive that is the payer Paula is having problems with...I don't use it with commercial payers...

  10. Default
    I do understand the concept that everyone is using the 59 modifier due to it being "Medicare".
    I thought the 59 modifier is stating separate procedure....separate incision.
    Wouldn't that make it wrong to add the 59 modifier just to get Medicare to pay....instead of the thought process that Medicare does not pay for closure as they do not pay for post-op office complications?


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