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denails for debridement add ons 11046

  1. #1
    Default denails for debridement add ons 11046
    Medical Coding Books
    Good Morning Coding world,

    I recieved denails from MCR for the add on codes 11045-11047

    The problem is that we bill for mulitple add on codes for a visit because the wounds are large in sq cms. MCR of MA and other states are denying our additonal add ons as duplicate because we use the same ICD 9 codes. When medicare was called, they said that in order to bill for additonal add on with the same DX codes we have to use 76 modifer. There is no publication on how to submit the DX codes with these add ons. I'm confused because what If there is only one LARGE wound debridement that in surface area requires additonal add ons. How do 76 modifier works?

  2. #2
    Location
    Columbia, MO
    Posts
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    Default
    It would help to see your op note. And FYI no you would not use the 76 modifier in this manner, that is for a repeated procedure in a different session. A debridement performed on a different area is not repeated. Can you supply the dx code used as well as all procedure codes and the op note?

    Debra A. Mitchell, MSPH, CPC-H

  3. Default wound care add ons
    Quote Originally Posted by coder1 View Post
    Good Morning Coding world,

    I recieved denails from MCR for the add on codes 11045-11047

    The problem is that we bill for mulitple add on codes for a visit because the wounds are large in sq cms. MCR of MA and other states are denying our additonal add ons as duplicate because we use the same ICD 9 codes. When medicare was called, they said that in order to bill for additonal add on with the same DX codes we have to use 76 modifer. There is no publication on how to submit the DX codes with these add ons. I'm confused because what If there is only one LARGE wound debridement that in surface area requires additonal add ons. How do 76 modifier works?
    They may have been given a work around solution to share with providers until the edits are fixed. There were some notifications that the edits were not correct on the new codes and that they would not be corrected until April, so for the first quarter we billed correctly-say a 200cm debridement into muscle with a total surface as
    11043 x 1
    11046x9-this is all on one line, not listed 9 times-
    and the system was denying 11046 as an MUE of 1 even though it states each additional 20sqcm! This is a system error and should be appealed until they get it corrected. You shouldn't change the dx codes because you are dealing with the same dx just reflecting the size of the wound with the add-on code.
    We use CSNap to appeal them and they get paid on appeal until they very recently starting paying correctly through WPS.

  4. #4
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Quote Originally Posted by MMAYCOCK View Post
    They may have been given a work around solution to share with providers until the edits are fixed. There were some notifications that the edits were not correct on the new codes and that they would not be corrected until April, so for the first quarter we billed correctly-say a 200cm debridement into muscle with a total surface as
    11043 x 1
    11046x9-this is all on one line, not listed 9 times-
    and the system was denying 11046 as an MUE of 1 even though it states each additional 20sqcm! This is a system error and should be appealed until they get it corrected. You shouldn't change the dx codes because you are dealing with the same dx just reflecting the size of the wound with the add-on code.
    We use CSNap to appeal them and they get paid on appeal until they very recently starting paying correctly through WPS.
    However 11046 in your example should be listed 9 times as it is each additional 20 sq cm, and it says to list separate. That is why the MUE is correct as the units should never be greater than 1 for a single line item. I read on the MCM website years back that units are to be used only for services that are quantity distributed such as timed services. Surgical services are not quantities they are each and each one is unique and distinc. So if it is denying for MUE due to units greater than 1 then that is a correct edit.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    Quote Originally Posted by mitchellde View Post
    However 11046 in your example should be listed 9 times as it is each additional 20 sq cm, and it says to list separate. That is why the MUE is correct as the units should never be greater than 1 for a single line item. I read on the MCM website years back that units are to be used only for services that are quantity distributed such as timed services. Surgical services are not quantities they are each and each one is unique and distinc. So if it is denying for MUE due to units greater than 1 then that is a correct edit.
    Thank you, but our medicare contractor instructed us to bill as I noted. If the contractor in your state has a different bill method, by all means use it. I gave you an example of ours. Clearly if they are correcting the system, they must have intended that it be used as a quantity bill.

  6. #6
    Default
    Just like the example from MMaycock its the same situtation besides I did bill the add on on seperate lines. The carrier told me 76, which I disagree totally. The problem I have is that every carrier from different states denied as duplicate but gave me different ways to bill. bill in units,use 76 modifier,etc. MMaycock could you let me know where you get the info for the edit error from WPS. I wish there was some clarification. The carriers are not helpful at this point.

    Thanks,
    Genova

  7. #7
    Location
    Columbia, MO
    Posts
    12,531
    Default
    The problem is a carrier is not to tell you how to bill a particular line item. They can be and most times are incorrect in what they tell you. The modifers and their meanings cannot be different from payer to payer. The definition of the 59 modifier fits for the additional line items of the code. However was the denial due to duplicate? and how did you have it listed on your claim?

    Debra A. Mitchell, MSPH, CPC-H

  8. #8
    Default
    Mitchelde,

    ITS NOT A DUPLICATE, DENIAL IS INCORRECT

    Its listed as 11043 7070570724
    11046 7070570724
    11046 7070570724

    no modifiers


    the 11043 and the 1st 11046 was paid

    If its an appeal issue then I understand, but for every claim is crazy!!!!

  9. Default Debridement
    Quote Originally Posted by coder1 View Post
    Just like the example from MMaycock its the same situtation besides I did bill the add on on seperate lines. The carrier told me 76, which I disagree totally. The problem I have is that every carrier from different states denied as duplicate but gave me different ways to bill. bill in units,use 76 modifier,etc. MMaycock could you let me know where you get the info for the edit error from WPS. I wish there was some clarification. The carriers are not helpful at this point.

    Thanks,
    Genova
    I will try to find the transmittal- but I checked the CMS MUE list today and the add-on codes are not there. So they should not have a quantity edit.

    You may want to try to bill it on 1 line as we do with WPS with a quantity of 9.

    What I've noticed is that they often deny corrected claims as dupes unless you correct them on CSNAP. If you don't have access, it is free and it is awesome.

    But moving forward, try your next batch with the quantity on one line and I'd love to hear how it works out.

    Good luck!

    Melanie

  10. #10
    Default
    Thank you Melanie,


    I also viewed the MUE Edits and notice the same thing. If you can find information that would be great!!!

    For now, I will check for April claims across the board to see if it was just an edit error.

    I appreciate the feedback , which is taken into consideration


    Thanks,
    Genova

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