“Outpatient surgery was performed at a surgical center. We billed Blue Cross for CPT 11750 (T5) and CPT 11730 x 3 (T2, T7, T9). But they only paid CPT 11750. And the denial reasons are: ARV – Quantity billed exceeds CMS medically unlikely edits (MUE) limit. Rebill within MUE limit if appropriate. 222 – Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is not patient specific. Usage: refer to the 835 healthcare policy identification segment, if present. So my question is, what is the limit to bill for ingrown nail surgery?”
So, four toenail procedures were performed on the same patient on the same date of service at a surgical center. Only one of the procedures was reimbursed. What gives? The first procedure that was performed, CPT code 11750 (Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal) – T5 was appropriately billed and was reimbursed. When the Medically Unlikely Edits (ie. MUEs) are accessed, the number is 6 which indicates that CPT code 11750 can be billed up to 6 times on a given date of service.
The second procedure that was performed, CPT code 11730 (Avulsion of nail plate, partial or complete, simple; single) X 3 (T2, T7, T9) was rejected for all three toes. When the Medically Unlikely Edits are accessed, the number is 1 which indicates that CPT code 11730 can only be billed 1 time on a given date of service. It was billed 3 times. Here is the problem. I am making the assumption that CPT code 11730 was billed at 3 units and that is the reason why it was not paid even one time.
How can the problem be rectified? Well, it is all about knowing the Medically Unlikely Edits and the correct CPT codes to bill. The CPT code that was not correctly utilized is CPT code 11732 which is defined as: Avulsion of nail plate, partial or complete, simple; each additional nail plate (list separately in addition to code for primary procedure). When the Medically Unlikely Edits are accessed, the number is 4 which indicates that CPT code 11732 can be billed up to 4 times on a given date of service.
What about the coding scenario? Well, first the NCCI edits must be accessed. CPT code 11730 is a Column 2 Code to CPT code 11750 within the NCCI edits and cannot be separately reimbursed without being appended by the appropriate modifier. Interestingly, CPT code 11732 is not a Column 2 code to CPT code 11730 within the NCCI edits, but it is a Column 2 code to CPT code 11750 and cannot be separately reimbursed without being appended by the appropriate modifier. The correct fashion to code the posted procedure set is the following:
11750 – T5
11730 – 59 or XS, T2
11732 – 59 or XS, T7
11732 – 59 or XS, T9
The 59 modifier indicates a Distinct Procedural Service.
The XS modifier indicates a Separate Structure. This is a service that is distinct because it was performed on a separate organ or structure.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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