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Sep 9th, 2016 - jswhit 2 

Multiple surgery denial by Medicare

Our office recently had a multiple surgery claim partially denied by Medicare. It includes 4 of 1 CPT® code for excision, another CPT® code for excision & 1 CPT® code for closure of all the excisions. We only received payment for the 1 individual CPT® excision & the closure CPT® code. The reason code given was CO-151: “Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.” Below is what appears on the EOB as well as the DX codes used. Any insights into what the issue(s) may be concerning payment would be appreciated. Thank you.

Modifier DX
11603 C44.722 not paid
11604 59 C44.619 paid
12034 59 C44.722, C44.619 paid
11603 76,59 C44.722 not paid
11603 76,59 C44.722 not paid
11603 76,59 C44.729 not paid

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Sep 11th, 2016 - LBAROGIANIS 250 

re: Multiple surgery denial by Medicare

If I could see the op report it would help. So how many incisions were there ? Was the location on one body part? Trunk or leg? Need more information. 11603 is up to 3cm so if you took out more than 12 cm on the leg than you would code 11606 (over 4cm).

11603:
INCLUDES:

Biopsy on same lesion

Excision of additional margin at same operative session

Full thickness removal including margins

Lesion measurement before excision at largest diameter plus margin

Local anesthesia

Simple, nonlayered closure

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Sep 12th, 2016 - jswhit 2 

re: Multiple surgery denial by Medicare

5 total excisions- 4 CPT® code 11603, 1 CPT® code 11604 & 1 intermediate repair CPT® 12034. Below are the locations of the excisions:

R lower leg proximal cpt: 11603 DX: C44.722
R lower leg medial cpt: 11603 DX: C44.722 (2 deg intent)
R lower leg distal cpt: 11603 DX: C44.722 (2 deg intent)
L lower leg cpt: 11603 DX: C44.729 (2 deg intent)
L shoulder cpt: 11604 DX: c44.619

CPT: 12034 DX: C44.722, C44.619

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Sep 13th, 2016 - LBAROGIANIS 250 

re: Multiple surgery denial by Medicare

Read this blog: https://www.aapc.com/blog/26192-skin-lesion-excisions/ If you don't need to send a corrected claim then you will need to appeal with the operative report and pathology report.

Let me know how it works out!

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