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Athena kick back

  1. #1
    Smile Athena kick back
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    Good Afternoon coding world,

    Our company just started using the Athena software. Our claims for procedure 42 for mutliple wounds that require Lt and RT are reading " Per the physician Fee Schedule, the 150 % payment adjustment for bilateral procedures does not apply to procedure 11042 because of physiology/anatomy or because the code description specifically states that it is a unliateral pocedure and there is an existing code for the bilateral procedure".

    Thank you for ur help in advance!

  2. #2
    Sioux Falls South Dakota
    Skin does not have laterality, therefore modifiers RT, LT, and 50 do not apply to procedures in the Integumentary system (with the exception of breast)

  3. #3
    Columbia, MO
    11042 is not by definition a bilateral procedure, it is a skin procedure and skin is one organ without laterality. So the RT and LT and 50 modifiers are not appropriate. If you perform two debridements in two spearate areas even if one is on the left and one is on the right you may code the 11042 twice with a 59 modifier.
    11042 59
    I am not certain if this answers your question, but maybe it helps to clarify.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Thank you for ur prompt response. We have been using the rt and lt modifiers for this procedure for years. We used them when the wound site is the same but on the rt and lt side of that body part. I understand this from school but since working here our group have received reimbursement billing this way


    11042 FOR RT LEG
    11042 FOR LT LEG

  5. #5
    Columbia, MO
    Medical Billing
    The Rt and LT modifiers are not appropriate for skin procedures. As stated above the skin has no laterality as it is one organ. Rt and Lt are to be use for inherently bilaterally procedures but performed only on the left or right side. The 76 is also incorrect as you did not repeat the procedure. A repeat procedure is to be the ecact same procedure repeated in a different session. When you perform the same procedure but on a different area of the body then it has not been repeated it is a distinct and separate procedure so you need the 59. This is a very important distinction as the 76 modifier with most payers will bypass the discounting that should occur when you have more than one procedure performed in the same session. You must remember that payment is not always an indicator of correct coding.

    Debra A. Mitchell, MSPH, CPC-H

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