Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for the Partial excision (28122). We decided that the Plan does not have to
pay for codes 28002 and 14040.
You asked the Plan to pay for codes 28122, 28002, and 14040. You say that the medical records support the
services billed. The Plan says that the medical records do not support the services billed.
We decided that the Plan has to pay for the Partial excision (28122).
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the Partial excision (28122). Our reviewer
says that the medical records support the billing of the -59 modifier with code 28122. Our physician reviewer
found the medical records support a portion of the services billed. Specifically, the billing of code 28122 is
correct. Unfortunately, this enrollee underwent a partial foot amputation to the distal aspect of the foot at the
metatarsal level. The billing code 28122 is correct. Further evaluation of the operative note does not support
the additional billing of 28002 or 14040. The incision and drainage were performed as the infected bone and
soft tissue was removed at the metatarsal level. Furthermore, a fish mouth incision was created at the
metatarsal level of the foot. Soft tissue was debulked in order to allow for a closure however no adjacent tissue
transfer or rearrangement was performed. Therefore, code 28122 was correctly billed. CPT codes 28002 and
CPT code 14040 were incorrectly billed as they should be considered an inherent part of the first procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Partial excision (28122) have been met. Therefore, we decided that the Plan
has to pay for the Partial excision (28122).
We also decided that the Plan does not have to pay for codes 28002 and 14040.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 28002 is Incision and drainage below fascia, with or
without tendon sheath involvement, foot; single bursal space. The definition of code 14040 is Adjacent tissue
transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10
sq cm or less.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for codes 28002 and 14040. Our reviewer says
that the medical records do not support the billing of the -59 modifier with code 28002 and do not support the
billing of code 14040. Our physician reviewer found further evaluation of the operative note does not support
the additional billing of 28002 or 14040. The incision and drainage were performed as the infected bone and
soft tissue was removed at the metatarsal level. Furthermore, a fish mouth incision was created at the
metatarsal level of the foot. Soft tissue was debulked in order to allow for a closure however no adjacent tissue
transfer or rearrangement was performed. Therefore, code 28122 was correctly billed. CPT codes 28002 and
CPT code 14040 were incorrectly billed as they should be considered an inherent part of the first procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of codes 28002 and 14040 have not been met. Therefore, we decided that the Plan
does not have to pay for codes 28002 and 14040.
f the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.