• Payer Denial of Exam Same Day as Minor Surgery


    Question: Our commercial payer denied our exam submitted the same day as an excision of lid lesion. They stated it was incidental to the primary procedure. Below is how we submitted. Should we rebill or appeal?
    Diagnosis D23.121 Benign eyelid lesion
    CPT: 92014 - 25
              67840 - 59 - E1

    Answer: Although medically necessary, if the established patient exam is performed solely to confirm the need for the minor surgery, it is not separately billable. Each surgery code payment is comprised of approximately 10 percent preoperative care, 70 percent intraoperative and 20 percent post-operative care. In the commercial payer mind, they did pay you for the exam. They just didn’t pay you separately. If the exam is truly significant and separately identifiable with supporting documentation, then consider appealing. The payer may or may not overturn the decision.

    Note: No need to append modifier -59 to the excision as there was not another service provided to unbundle. Unbundling CCI edits is the primary use of modifier -59.

    Learn more about modifiers in the Learn to Code the Essentials.