Medical Posted Wed 26th of November, 2014 16:27:23 PM
On 9-23-14 we billed CPT 12032-59 and 11606 DX 173.61. On 10-3-14 the patient returned we billed 21550 and 17004-59. United Health Care have denied our claim for DOS 10-3-14 CPT's are included in CPT 12032 for DOS 9-23-14. The global period is 10 days. What is the proper modifier should I use to rebill DOS 10-3-14 CPT 21550 DX 238.2 and 17004 DX 709.2. I have read the description for modifier 54, 55, 58, and 79 I'm not sure which best fit this scenario.
SuperCoder Answered Wed 26th of November, 2014 20:04:37 PM
Thanks for your question. Procedure codes 11606; Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm and 12032;Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm both have 10 day global periods. Being that the patient returned on the 11th day, you may want to call the insurance company to make sure the denial is accurate. If you determine that the denial is accurate, explanations for the modifiers 58 and 79 may guide you. Please review the following information and determine which modifier will apply. I am unable to give you the modifier to choose without additional information regarding the case. It does appear that you would choose between modifiers 58 and 79.
Modifier 79; Unrelated procedure or service by the same physician during the postoperative period. Determine if the procedure is related the surgery that prompted the global period. If the second surgery takes place on a different body part or different side of the body, modifier 79 is likely the right one.
According to CMS guidelines, you would use modifier 58 (Staged or related procedure or service by the same provider during the postoperative period) when a second surgery is performed in the postoperative period of another surgery when the subsequent procedure was: planned or "staged" or more extensive than the original procedure; or for therapy following a surgical procedure; or for the reapplication of the cast within the 90-day global period.
Please see the following links for additional information. Hope this helps.