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Medicare denial

E. maria Posted Mon 05th of October, 2015 19:28:54 PM

We need your advise. patient underwent a partial mastectomy (19301) in June 2015, because of positive margins, pt was taken back to surgery in July 2015 a another partial mastectomy. Due to multiple positive margins a large excision was done which created a large hole in the upper half of the breast. At this point, oncoplastic advancement flap was done and a tissue flap was raised under the nipple and extended down to the inferior breast. Advancement flap was 20 cm. We billed MDCR w CPT codes 19301-58 for the mastectomy and and 14001 for the oncoplasty. MDCR has denied payment for the mastectomy stating this is included. I do no find any bundling issues. Please advise.

SuperCoder Answered Tue 06th of October, 2015 08:41:28 AM

Well, you are right, there is no CCI edits relationship between both the procedures, it should be paid ideally. As there are multiple positive margins, mastectomy is a necessity, due to this 19301 should be paid along with 14001 (if performed). It is advisable to appeal again and do not forget to provide the proper documentation with the claim form. On the other hand, you need to check the policy of the MDCR, there might be some clause related to the specific procedure, just confirm it with the insurance company. Hope this helps!

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