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Thread: Athena kick back

  1. #1
    Join Date
    Apr 2007
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    MIAMI
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    Smile Athena kick back

    Promo: Code Books
    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
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    Apr 2007
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    Sioux Falls South Dakota
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    358

    Default

    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)
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

  3. #3
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    Apr 2007
    Location
    Columbia, MO
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    Default

    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
    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
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    Apr 2007
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    Question

    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

    eg;

    11042 FOR RT LEG
    11042 FOR LT LEG
    MODIFER USED 76 FOR REPEAT PROCEDURE.

  5. #5
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    Apr 2007
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    Default

    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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