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Last Modified: 11/6/2019 Location: FL, PR, USVI Business: Part A, Part B

Be sure you are billing correctly for biopsy services - new CPT codes are in effect

First Coast would like to ensure providers performing biopsy services understand how to properly bill and code for these procedures. Recent data indicates improper billing so we want to provide clarification of top issues we identified.
Effective for dates of service on or after January 1, 2019, CPT (Current Procedural Terminology®) biopsy codes 11100 and 11101 have been deleted, and new biopsy codes 11102-11107 are now 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 indicates 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 Healthcare Common Procedure Coding System (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:

NCCI resources:

Duplicate resources:

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.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.