Modifier madness
Cracking the Code
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
By Alexander Miller, MD, April 1, 2019
You, your office staff, and your biller are confident in your use of the new biopsy codes. You realize that when multiple biopsies of any type: tangential, punch, or incisional, are done during one patient encounter, you should report only one primary code (11106, 11104, 11102). You report additional biopsies with add-on codes 11107, 11105, 11103. As these are add-on codes, a 59 modifier should not be appended to them.
However, what happens when you perform totally different procedures along with biopsies? Which procedures need a modifier 59 and which would not? You, your staff, and your billing software should know the modifier placement convention to assign modifiers to the appropriate code.
The National Correct Coding Initiative (NCCI) recently confirmed that regardless of which of two paired codes identified in the NCCI Procedure-to-Procedure (PTP) Column 1/Column 2 edits receives a 59 modifier, the higher-valued code should be reimbursed at its full value and the lower-valued code should receive a multiple procedure reduction in payment. Physicians will be able to append the 59 modifier to either the Column 1 or Column 2 code. The reason for this shift is the Centers for Medicare and Medicaid Services' (CMS) effort to ensure the multiple surgical reduction policy that allows the higher value code to be reimbursed at 100% and the lesser value code to be reimbursed at 50% — initiated 13 years ago — is adhered to by all MACs.
However, your Academy coding staff noted that your local Medicare Administrative Contractors (MACs) have been strictly requiring that the modifier be appended to the Column 2 code. A claim with a modifier appended to the Column 1 code will not be paid. This disparity between how NCCI assumed claims were being adjudicated and what has actually been happening has now been acknowledged by CMS.
On Feb. 15, 2019, CMS issued Change Request 11168, which stipulates that as of July 1, 2019, service modifiers 59 and XE, XS, XP, and XU may — when appropriate — be appended to either Column 1 or Column 2 codes. The claims processing systems that MACs use will be modified to accept the modifiers on either Column 1 or Column 2 codes. Until that time, you should make sure that any modifier is appended to the Column 2 code in the NCCI PTP edits list. For more information, visit www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R2259OTN.pdf.
Whether private insurers will follow CMS guidelines for claims adjudication in this type of scenario is not known. As always, it is wise to keep track of claims adjudication patterns and adjust modifier placement accordingly by using the NCCI PTP coding edits found at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html.
Select skin biopsy NCCI PTP code pairings, that may not be intuitively obvious, are listed below:
For a full list of NCCI code pairings, visit www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html.
Case 1: You freeze an actinic keratosis and also tangentially biopsy a suspected basal cell carcinoma on a Medicare patient. You report the freezing with CPT 17000 and the biopsy as 11102-59.
Answer: Incorrect. What? Prior to this year all destruction codes were listed in Col 1 and the integumentary biopsy code in Col 2. Well, as of this year selective permutations of previous code listing convention have surfaced. One of these involves 17000 and 11102. Since 11102 is higher valued than 17000, 11102 is listed in Col 1 and 17000 in Col 2. You would report this encounter as 11102, 17000-59.
Case 2: Ah, now you have it figured out! In your Noridian MAC area, CPT 17004 is reimbursed at a pennies-higher rate than 11106. After destroying 17 actinic keratoses and doing an incisional biopsy of an unrelated skin lesion, you report 11106 for the biopsy and 17004-59 for the destruction of actinic keratoses.
Answer: Incorrect. Argh! What happened? CPT 17004 is listed in Column 1 of PTP edits paired with all the biopsy types, 11102-11106, in Column 2. Until claims start being adjudicated and paid, regardless of which of the paired codes receives an appended modifier, it behooves one to follow the NCCI edits placements. 17004 (destruction, premalignant lesions, 15 or more lesions) remains in Col 1 paired with all the biopsy codes in Col 2. You would report this encounter as 17004, 11106-59.
Case 3: You receive a Medicare claim denial. Suspecting that it is due to misplacement of the 59 modifier on a Col 1 code rather than Col 2, you resubmit a corrected claim.
Answer: Correct. Simple code corrections, including modifier placement, may be done via a reopening of a Medicare claim. Claims denied due to absent modifiers or incorrect modifier placement may simply be resubmitted in their corrected form. In such cases, if part of the claim was adjudicated appropriately and paid, only that portion requiring a repositioning or placement of the modifier should be resubmitted. Claims with message MA130 (Returned as unprocessable claim) or N704 (Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted) on Electronic Remit Advice (ERA) or Standard Paper Remit (SPR) must be resubmitted as a corrected claim.
Case 4: A patient comes in with a large suspected squamous cell carcinoma on the scalp and a presumed basal cell carcinoma on the ear. You do a tangential biopsy on the scalp and a tangential biopsy on the ear. You report CPT 11102 for the scalp biopsy and 11103 for the ear biopsy.
Answer: Incorrect. Two problems surface here: Incorrect code for the ear biopsy, and lack of modifier placement. The CPT provides a dedicated code for ear biopsies: 69100. Additionally, in the NCCI PTP listing, 69100 is in Col 1 and skin biopsy (11102) is in Col 2. Correct coding is: 69100, 11102-59. Although both are biopsies, they involve codes from completely different numerical series. Consequently, for the additional biopsy, one would report the primary, 11102 tangential biopsy code rather than 11103, each separate/additional lesion.
Case 5: Two punch biopsies are done on unrelated lesions, one on the penis and the other on the cheek. The penile biopsy is reported with CPT 54100, biopsy of penis, and the cheek biopsy with 11105 for the additional biopsy.
Answer: Incorrect. Although two primary biopsy codes are correctly selected, since they are placed in separate code series in the CPT, they are paired in the NCCI PTP edits. The cheek punch biopsy should be reported as 11104-59.
Case 6: You do a broad incisional biopsy of suspected cheek lentigo maligna. Due to skin tension across the line of closure, you do a layered closure of the biopsy defect. Since closure is included in the incisional biopsy definition, you report CPT 11106 for the biopsy.
Answer: Incorrect. An incisional biopsy includes a simple repair in its definition. In this case, a layered repair was done. Consequently, it is appropriate to also report an appropriate intermediate repair code, CPT 12051-12057 with a 59 modifier.
Note: Effective July 1, 2019, this will change when the new NCCI edits take effect. Providers will be able to append the modifier to whichever code they choose.
