George Posted Wed 01st of May, 2013 15:48:00 PM
I am getting a denial from Medicare for the use of
12001. The denials are M144 and M80. We have tried to append modifier 51. Are all of these codes incidental to 49083?
SuperCoder Answered Fri 03rd of May, 2013 12:23:34 PM
1. CPT 12001, simple repair is always included in the main procedure, so do not code this separately.
2. CPT 36410 has CCI bundling with 49083, you can use this code with modifier 59 if the procedure is distinct and there is documentation to justify this.
3. CPT 99070 is considered inclusive and Medicare does not pay for this procedure.
Please read this article:
AMA and Medicare already factor essentials into a code's values on the physician fee schedule. If you're doing a procedure in the office that requires tools, surgical trays, or other supplies, the reasonable expectation is that you will be using equipment and that those costs have been accounted for in the price's procedure.
The site of service differential in the Medicare fee schedule, which pays more for this procedure when done in the office versus a facility, is meant to include these supplies and services.
Example: if the doctor does a biopsy in the office (such as 11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion), he will use equipment to do it, and he may need to close the biopsy site with simple closure by suture or bandage. These supplies are considered bundled into the biopsy code and are not separately billable.
Exception: Private payers that do not follow the Medicare fee schedule might not include supply costs in their payments. In these cases, you could be paid for the item(s) by reporting 99070 (Supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drug, supplies, or materials provided]) for items that incur a cost in the office (POS 11). Check with the commercial payer to determine if this service is separately billable.
George Posted Tue 07th of May, 2013 20:48:27 PM