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Jun 27th, 2018 - gowri.tina

Aetna denial on E/M codes

Aetna denies E/M visit - cpt 99212/ 99213 when billed with radiation code cpt 77401. It denies cpt 99212 as " pre-post operative care payment is included in the allowance of surgery/procedure, start:01/01/1997"

As per Medicare guidelines 'In radiation oncology, evaluation and management CPT codes are not separately reportable except for an initial visit at which time a decision is made whether to proceed with the treatment.
Subsequent evaluation and management services are included in the radiation treatment management
CPT codes." But medicare pays the E/M visits (LCD L34652)

Could anyone clarify any alternate solution so as to get payment from Aetna

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Jul 9th, 2018 - MargeM   11 

re: Aetna denial on E/M codes

Medicare guidelines do not apply to private carriers. You need to check your contract with Aetna or call and get their guidelines for billing E/M with 77401. It might require a modifier to be paid.

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