Review Results for Service Specific Postpayment Review of Tangential Biopsy of Skin; Single Lesion CPT 11102 with Destruction, Premalignant Lesion; First Lesion CPT 17000

In an effort to reduce the Part B CERT error rate, the MR Department conducted a service specific post payment review of CPT code 11102 (Tangential biopsy of skin; single lesion) AND CPT code 17000 (Destruction, premalignant lesions; first lesion). The primary focus of these audits was to determine whether the medical necessity of the services billed was at the correct code per Medicare guidelines.

NGS randomly selected 150 claims billed for CPT 11102 and CPT 17000 for post payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

• CPT code 11102 (Tangential biopsy of skin; single lesion
• CPT code 17000 (Destruction, premalignant lesions; first lesion)

Results

Decision	Number of claims
Allow	103
Deny	3
Partially Deny	2
Nonresponse Denial	42

 

• 93  claims from Illinois with 57 allowed and 36 denied for a claims error rate of 38.71%
• 30 claim from Minnesota with 24 allowed and 6 denied for a claims error rate of 20.00%
• 27 claims from Wisconsin with 22 allowed and 5 denied for a claims error rate of 18.52%

Key Reasons Services were Denied

• Documentation did not support medically necessity due to one or more of the following: records did not clearly support the lesion removal
• Documentation was insufficient or incomplete
• Failure to respond to the request for documentation

Recommendations

• Send the requested records within the requested time frame to avoid a denial for no documentation
• Familiarize yourself with available removal of benign skin lesions use guidelines and other CMS publications listed below
• Share this information with your coding personnel to ensure they are properly billing before sending the claim to Medicare
• If you feel your application of this code is correct, ensure your documentation supports your usage

Related Content

• CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16: Section 20 and Section 180
• National Correct Coding Initiative Policy Manual, Chapter 3
• Local Coverage Article: Billing and Coding: Removal of Benign Skin Lesions A54602
• Title XVIII of the Social Security Act 1862(a)(1)(A)
• Title XVIII of the Social Security Act 1833(e)

Posted 12/13/2021