Author Topic: Breast Reconstruction  (Read 1123 times)

kristy7

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Breast Reconstruction
« 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

Michele

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Re: Breast Reconstruction
« Reply #1 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.
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kristin

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Re: Breast Reconstruction
« Reply #2 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.

kristy7

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Re: Breast Reconstruction
« Reply #3 on: December 16, 2015, 10:16:54 AM »
thanks for the help!!