09/23/2021

Excellus Denial for Bilateral CPT 11000

11000 bilateral - have tried modifier 50 and modifiers 51/59 - both have been denied for improper use of modifiers

The claim was correctly denied by Excellus for improper modifier use. CPT code 11000 (DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE) is a procedure that is billed based on the amount of skin that is considered to be infected or eczematous. Regardless, if there is more than one place on the patient’s body that was treated, the definition of the code is based on the amount of skin treated with their total body area.

It is extremely unlikely that addressing the skin on two toes would be greater than 10% of the patient’s total body area (in the event that it was, those specific measurements would need to be documented in the notes/op-report to justify the extent of the procedure). CPT 11000 would never be billed more than once per encounter. If the documentation does prove extensive debridement was performed, the add-on code (CPT 11001, DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; EACH ADDITIONAL 10% OF THE BODY SURFACE, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) would need to be billed for every additional 10% of the body surface that was treated. This would need to be coded with modifier -59 to be considered separately from the bilateral nail avulsions.