How You Can Avoid These Mistakes
T his month I’m highlighting a handful of questions that I found quite interesting regarding various claims processing scenarios. In each case, I’ll share some insight on what the billers did wrong, so that you can avoid making the same mistakes and not lose out on the reimbursement you deserve. In all instances, the claim to the insurance carrier was denied in-part or in-full due to some error that the doctors’ billing staff made. In the busy, rushed atmosphere of most physician practices, mistakes are inevitable. Hopefully, by learning from these billing mistakes, your office will not be destined to repeat history. Q: I recently billed for the excision of a basal cell carcinoma of the left cheek that was repaired with an adjacent tissue transfer. The basal cell carcinoma measured 1.6 cm in diameter, and the flap measured 10.1 square centimeters. I billed the excision using CPT code 11642 with a diagnosis of 173.9. The flap was billed using CPT code 14041. I attached modifier 59 to the excision code, but the excision was still denied. What did I do incorrectly, and what should I do to get the excision paid? A: Several main points need clarification. First and foremost is the ICD-9-CM diagnosis code that you assigned to CPT code 11642. Diagnosis code 173.9 refers to a malignant neoplasm of the skin of an unspecified site. But you know the exact site of the cancer — it’s the left cheek. The site-specific diagnosis code for the cheek is 173.3. Most carriers are no longer paying for the “catch-all” code categories such as 216.9, 171.9, 172.9, 173.9, 215.9 and 232.9 because more specific codes are available. Carriers are denying these junk codes because they’re non-specific and do not match the site-specific CPT code that they’re linked to. So stop using the .9 codes for the six categories mentioned above and offer specifics based on the exact anatomical location. I’ll list them below for your reference. Use the fourth digits listed below in conjunction with ICD-9 codes 172, 173, 216 and 232: .0 = Lip .1 = Eye including canthus .2 = Ear (pinna) .3 = Face, other and unspecific parts .4 = Neck and scalp .5 = Trunk, except scrotum .6 = Upper extremities including shoulder .7 = Lower extremities including hip .8 = Other specific sites. Use the fourth digits listed below in conjunction with ICD-9 codes 171 and 215: .0 = Head, face, neck .2 = Upper limb, including shoulder .3 = Lower limb, including hip .4 = Thorax .5 = Abdomen .6 = Pelvis .7 = Trunk, unspecified .8 = Other specified sites of connective and other soft tissue. Now your biggest problem is unbundling! You absolutely cannot bill the excision code in conjunction with the repair if the same site is closed with an adjacent tissue transfer. Excisions are included in the payment for all services ranging from CPT codes 14000 to 14300. Billing the excision with the modifier 59 indicates that the service is unrelated, which it is not. You are therefore misrepresenting the service and, in essence, filing a false claim. The definition in CPT for codes 14000 to 14300 specifically states that the services include the excision. This applies to all carriers, not just Medicare. So the bottom line is that you cannot bill for the 11642 code. You should write it off. Q: I work for a Mohs surgeon. It is not uncommon for him to take a final piece of tissue (after he has clean margins) and send it off for a permanent slide to be made. The obvious CPT code is 88305 for the permanent slide. I have a lot of problems getting this paid even with modifier 59 attached. How can I get reimbursed for this? A: You cannot bill the 88305 code. Most pathology services billed in conjunction with Mohs (CPT codes 17304 to 17310) are included in the Mohs services and cannot be separately billed. If your boss wants to continue making the slides for his personal edification, then he (or she) will have to bear the expense of that permanent slide. You cannot bill the carrier for that slide, and billing it with modifier 59 is not allowed because it is a misrepresentation of your service. Q: I try over and over again to get the doctor for whom I work for to stop performing multiple services on one patient during the same date of service. However, he is so busy that he feels that it’s better to address all of the patient’s concerns at once since it could be months before the patient can reschedule an appointment. I’ve included a common example of how many services I have to bill on one date. I never seem to bill correctly in these multiple scenarios as some or more codes always get denied. Please explain how I should correctly bill for the services listed below. In this example, there were two lesions. Both were cancers that were treated, and I billed for the following: Lesion #1 Lesion #2 11602 11602 13101 13101 88305 88305. A: What typically happens is that the greater the number of services performed on one date of service (DOS), the more likely there is for the chance of claims denial. Sometimes, even if the services are correctly coded, the carrier will deny them — for whatever reason. So, first, keep trying to get your employer to limit the number of services billed on the same DOS. Then make sure you code correctly. Here are some tips: 1.When multiple surgical services are billed on the same date of service, do not bill them in units. Since they are subject to the multiple surgical reduction rule, the carrier must know how much you charge for each service on the claim. Therefore, they must be billed on separate lines. Most carriers prefer modifier 76 when identical CPT codes are billed on the same date of service. Some prefer modifier 59, while a limited number require modifier 51. 2.Pathology services are not subject to the multiple surgery reduction rule, so they can be billed on the same line on the CMS-1500 form regardless of whether or not they have different ICD-9-CM codes. Just pick one of the diagnosis codes and bill for it. 3.When lesions are repaired using the same type of closure (such as intermediate or complex repair because they are in the same anatomical classification), you cannot bill these separately. You must add them together (based on the lengths of all the defects) and bill them as one CPT code on one line of the CMS-1500 form. Keep in mind that this rule does not apply to flaps and grafts. The answer to your questions then is as follows: 11602 11602 -76 13101 (or 13102 depending on the total length) (no modifier needed on this one) 88305 x 2 units. Q: I billed the following procedure codes and was denied the payment for the biopsy services. What did I do wrong? 99213 -25 / 11100 -59 / 11101 -59 A: First and foremost: You must learn how to use modifier 59 correctly. Medicare is now denying services where modifier 59 is billed incorrectly, or added unnecessarily. In your case, there was no need for modifier 59 at all, so the biopsy service was denied. Call (800) 318-3271 for more information about DermCoder software (available for $99.00) that includes the latest version of all Correct Coding Initiative bundled services. This software will help you easily determine whether modifier 59 is needed and, if so, on which CPT code(s) it is placed. Remember, if you don’t need the modifier and you attach it incorrectly, it will result in unnecessary claim denials. Q: We have a large physician group, but at this time we have only one dermatopathologist. We contract with an outside reference laboratory that makes all of our slides. They bill us directly for all the slides they make for us each month. We then turn around and bill the insurance carriers. The lab also has one dermatopathologist. Sometimes, when our dermpath has a difficult slide, he will ask the dermpath in the outside lab to consult with us. The outside dermpath will read the slide and generate a consultation pathologist report of his opinion on the slide. I understand the correct CPT code is 88323, but I am unsure of what I missed or where I made an error as 88323 is always denied. A: It’s really a simple answer. Your office cannot bill for the consultation performed by a provider who is not under your employment. Yes, you can purchase the technical component of a laboratory service, but not the professional component. In your example, the professional component must be billed by the entity that actually performed the service. In this case, it is the outside lab that makes your slides.