January 23, 2014
My surgeon is performing bilateral nipple reconstruction with skate flaps and full thickness skin grafts. She would like to use codes 19350 (nipple/areola reconstruction) billed on two lines with LT/RT and 59 modifiefs,15200 (full-thickness graft) on two lines with LT/RT and 59 modifiers and again 15002 (surgical preparation) on two lines with LT/RT and 59 modifiers. We are getting reimbursed for both 19350 but only one 15200 and one 15002. Are we doing something wrong? Why aren’t we getting paid for all these procedures?
The code for nipple/areola reconstruction, CPT 19350, includes any and all procedures necessary to reconstruct the nipple/areola including harvesting and placing of grafts. Therefore, it would not be appropriate to separately report codes for grafts such as 15200. It also would not be appropriate to report a wound/scar excision code such as 15002 as this activity is included in 19350. So I would write off the charges for 15200 and 15002 and I would not separately bill these codes with 19350 in the future.
Also, 19350 accepts modifier 50 per Medicare and most payors. So it should not be necessary to use modifier 59. There are two ways to use format your claim using modifier 50:
1) Line-item format: listing the code on two separate lines and modifier 50 is appended to the second code.
|19350||1 unit $your single fee|
|19350-50||1 unit $your single fee|
2) Bundled format: listing the code on one line with modifier 50 but doubling your fee
|19350-50||1 unit $double your single fee|
Medicare recognizes format 2 (bundled) and will pay 150% of the single code allowable. Other payors may want format 1 (line-item).