06/10/2020

Magnacare Denial for Ulcer Debridement

The last three times I billed ulcer debridement to magnacare they have denied me with code 04-"modifier not allowed with submitted codes and or professional component is not payable for submitted codes " I used CPT code 97597 modifier T5 with diagnosis code I70.235 and L97.511 they're also giving me the same error code when I bill 11042 with the appropriate ICD-10 codes. Is anyone else seeing this problem?

When billing for an ulcer debridement, no site or toe modifiers should be used. By the definition of the procedure code, it is based on the number of square centimeters treated, regardless of location. It is unnecessary to add a modifier when the laterality does not give important information on where the service was rendered. Details about the location or laterality should be documented in the progress notes, or with a valid diagnosis code, but are not needed on a claim for CPT codes 11042-11047 as a modifier.