Question

CPT codes 11400 and 12031 were reported on a claim. The insurance carrier denied 12031 as bundled with 11400. According to CPT® guidelines for Excision for Benign Lesions what action should the biller take?

a.Write-off 12031 as repairs are included in excisions.
b.Add modifier 59 to 12031 and submit a corrected claim.
c.Add modifier 51 to 12031 and submit a corrected claim.
d.Appeal the claim.

Answer 1

The biller should add modifier 59 to CPT code 12031, if the procedures are separate, and then submit a corrected claim.

Step-by-step explanation:

If CPT codes 11400 and 12031 were reported on a claim and the insurance carrier denied 12031 as bundled with 11400, the action the biller should take according to CPT® guidelines for Excision for Benign Lesions would be to evaluate whether the two procedures are sufficiently separate. If the repair procedure represented by code 12031 is distinct because it was performed on a different lesion or a different part of the body, then modifier 59 should be added to code 12031 to indicate that it is a distinct procedural service. Afterwards, a corrected claim can be submitted with the modification.