Medical Billing Forum

Coding => Coding => Topic started by: kristy7 on December 04, 2015, 11:29:17 AM

Title: Breast Reconstruction
Post by: kristy7 on December 04, 2015, 11:29:17 AM
The insurance company is stating 13101 has an unbundle relationship with 19342.  No matter how I code the modifiers, 13101 is denied.

19342
11970 - 59
13101 - 59
36590 - 59

Operative Procedure:
1 Revision of L breast with exchange of tissue expander for permanent implant
2 R breast exchange of tissue expander for permanent implant
3 revision of dog ear L back 6cm
4 removal of chemo port
Title: Re: Breast Reconstruction
Post by: Michele on December 04, 2015, 01:51:00 PM
I'm not sure but I believe that they are stating that they do not allow the unbundling of 19342 & 13101.  So even the use of a modifier will not make any difference.  Have you tried to contact the insurance carrier to get a verbal explanation?  Also, they may be able to point you to written material on the subject (depending on the carrier).  I do not have experience with breast reconstruction surgery and I am not a certified coder but I believe they are stating that they do not allow separately for the trunk repair and the insertion of the prosthesis. 

The following post on AAPC has a lot of information on breast implant surgery:  https://www.aapc.com/memberarea/forums/showthread.php?t=3755 

I hope that helps.
Title: Re: Breast Reconstruction
Post by: kristin on December 04, 2015, 02:56:09 PM
It looks to me like the insurance company may think that the 13101 code was for the left breast, as a wound repair/closure code, after the revision was done(which would bundle), but it was actually for a dog ear on the BACK of the patient. Separate area, separate incision, therefore the 59 modifier is allowed, and NCCI edits on the 13101 show this to be the case. I would contact insurance, explain this to them, and see if they won't adjust the claim. If not, you should appeal with the op report.
Title: Re: Breast Reconstruction
Post by: kristy7 on December 16, 2015, 10:16:54 AM
thanks for the help!!