Be sure you are billing correctly for biopsy services

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Home ► Billing news ► Be sure you are billing correctly for biopsy services

Last Modified: 2/29/2024 Location: FL, PR, USVI Business: Part A, Part B

Be sure you are billing correctly for biopsy services

First Coast would like to ensure providers performing biopsy services understand how to properly bill and code for these procedures.

Effective for dates of service on or after January 1, 2019, CPT biopsy codes 11100 and 11101 were deleted, and biopsy codes 11102-11107 are in effect as defined below:

• 11102 Tangential biopsy of skin (e.g., shave, scoop, saucerize, curette); single lesion

• 11103 each separate/additional lesion (List separately in addition to code for primary procedure)

• 11104 Punch biopsy of skin [including simple closure, when performed]; single lesion

• 11105 each separate/additional lesion (List separately in addition to code for primary procedure)

• 11106 Incisional biopsy of skin (e.g., wedge) (including simple closure, when performed); single lesion

• 11107 each separate/additional lesion (List separately in addition to code for primary procedure)

Data has indicated that biopsy claims are being denied due to improper billing submissions such as:

• Biopsy codes are being billed with other surgery codes on the same date of service; however, the 59 modifier (defined as “a distinct procedural service”) is being applied to the other surgery code instead of the biopsy code. The biopsy code is being denied due to National Correct Coding Initiative (NCCI) editing.

• In these cases the 59 modifier should be appended to the biopsy code, if applicable.

• Biopsy codes are denying because they are exceeding the CMS Medically Unlikely Edits (MUEs). An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

• Biopsy codes are denying because the wrong primary code is being billed or no primary code is billed at all.

• Biopsy codes are denying because they were billed with a screening diagnosis.

Below are tips and links to assist with proper billing of these services:

MUE resources:

• CMS MUE page external link

NCCI resources:

• Tool: NCCI procedure-to-procedure lookup

• Denial reason code CO236 FAQ

Duplicate resources:

• Preventing duplicate claim denials

• Denial reason code OA18 FAQ

Tips:

• For procedure codes 11102, 11104, and 11106, you may only bill one unit per line item.

• For procedure codes 11103, 11105, and 11107, you are permitted to submit multiple units on a single line item to prevent duplicate denials.

• Based on the above-referenced article, the system will allow the first line without a modifier and the second line with the appropriate modifier, then will deny subsequent lines as an exact/suspect duplicate.

Please be sure to review your documentation and how your codes are being selected and submitted.

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