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Ashley Posted Mon 14th of November, 2011 21:00:26 PM

A patient presented to my general surgeon's office with complaints of hidradenitis. He decided to proceed with surgery. His (abbreviated) op note reads: "The patient had scarring in the medial aspect of both inframammry folds from hidradenitis recurrent infections. Both ares were inscribed with a marking pen 15 cm in length and 4 cm in width on the right and 17 cm x 4 cm on the left. Skin incisions were made with a #10 blade scalpel. The skin and subcutaneous tissue were excised down to the muscle fascia and submitted to pathology." *Please note that the pathology did not mention that the sweat glands were excised.
My physician billed this procedure as follows: 12035, 12035-51, 11406-51 and 11406-51. Was this billed correctly? I ask because the patient's insurance company is not wanting to pay for 12035-51. They paid for the other 3 charges except 12035-51 citing 12035 can not be billed bilaterally (even though modifier -50 was not appended). Should the measurements of 12035 been added together? That way only one repair CPT code would have been billed.
Thank you in advance for your help.

SuperCoder Answered Tue 15th of November, 2011 00:26:52 AM

You have coded it wrongly.
While doing coding for repair, you should not code it differently with RT/LT or modifier 50. The Rule: With multiple wounds of the same complexity and in the same anatomical area, the length of all wounds sutured is summed and reported as one total length.
So, you should have billed 12037 once only. You have really lost more than $100 approx. due to wrong coding.
Now, the Ins.is not going to reimburse 12035 for the second one.
The only corrective step is to refile with 12037 and ask for additional amount. This has to be submitted with along with documentation and medical records. For this, perhaps you may first need to refund the payment of 12035 that you had already received(I am not sure).

Ashley Posted Tue 15th of November, 2011 17:24:02 PM

Thank you for the information Sanjit.
I have another question, was billing 11406 twice correct since the CPT code should have only been 12037?
Thank you again for your help.

SuperCoder Answered Tue 15th of November, 2011 18:23:51 PM

It is correct to bill 11406 twice, while coding 12037 once.
Reason:While coding excisions, we code it individually, and don't add them up. But, while coding repair we have to add up the length by anatomical divisions as per description of the code.
But, while coding excisions multiple times, (say 11406 twice), ideally we should attach modifier 59, but payer preference is to be given on modifiers. If the payer pays with modifier 51, then it is not wrong.

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