Ms. Codit

January 1, 2005

Although everyone in the medical billing environment tries hard to follow all the rules set forth by the many managed care plans, the American Medical Association, Children's Medical Services, the Office of the Inspector General, as well as State and Federal statutes, mistakes do occur.

Here is a collage of innocent mistakes made by billing staff and/or providers and the correct way the claims should have been billed. We hope our readers will learn from their mistakes.

Q: My physician excised a small nevus of the back with 5 mm/d punch. He placed two sutures. We billed CPT codes 11400 and 12031. We received a denial from the insurance carrier for CPT code 12031. We appealed the denial with our operative note which clearly documented both the excision and the repair. What is our next step? We feel we should be paid for both.

Q: We recently billed an office visit (CPT code 99213), a skin biopsy (CPT code 11100) and three destructions (CPT codes 17000 and 17003). The carrier paid codes 99213, 11100 and 17003 in full, but reduced code 17000 by 50 percent. I was under the impression that CPT code 17000 was not subject to the multiple surgery reduction rule. I appealed the reduction but was unsuccessful. Can you provide me with documentation that I can send to the carrier to show them they made a mistake in reducing this service?

A: Oops! Your impression was incorrect. First, carriers can reduce anything they want if you signed a contract giving them such permission. You'd be surprised at how vague and nebulous language in your contract could give them such leeway. At any rate, I know of no documentation in any reliable source that confirms your assumption. You may be confusing CPT code 17004 which Medicare has determined is not subject to the multiple surgical reduction rules. However, Medicare does reduce CPT code 17000 if billed with other surgical services with higher relative value units. The carrier paid you correctly.

Q: We have a large group single-specialty practice made up of seven dermatologists. Recently, a patient was seen by two physicians in our practice on the same date of service. I will refer to them as doctors A and B. Dr. A is a Mohs surgeon and was seeing the patient for a follow-up for a recent skin cancer removal with an adjacent tissue repair. During his post-op visit he saw an actinic keratosis and treated it with liquid nitrogen. Dr. A did not bill for the office visit, but billed CPT code 17000 with the -58 modifier for the destruction. That same day, Dr. B (the patient's regular dermatologist) also saw the patient for his six-month skin check. He did a full-body exam and also treated 10 actinic keratoses. Dr. B billed 99214-25, 17000 and 17003 (at nine units). The insurance company (Medicare) denied the 17000 performed by Dr. B. Our medical record clearly shows that 10 lesions were treated. Why was this denied and what should we do to get it paid? Should Dr. B have used a modifier and if so, which one?

A: Oops! I have the feeling that you billed incorrectly, but I have lots of questions that need to be answered first.

1. Why did Dr. A not tell his colleague, Dr. B, to treat the actinic keratosis? After all, the patient was referred to him for the Mohs only and Dr. A knows that Dr. B follows the patient regularly.

2. Why was modifier -58 appended to the 17000 billed by Dr. A? Why would this be represented as a staged service? No modifier is needed. I assume that the patient was not in the postoperative period of the recently performed Mohs. If the postoperative period was still in effect, the correct modifier should have been -79.