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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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Jul 17th, 2018 - MarinENTzac 5 

Aetna denial on E/M codes

99213/99212(E/M) is a column 2 code to 77401 but can be billed with a modifier. So, if the patient is seen for something else (a separate diagnosis code for example) then you can bill both. But if the patient is coming in solely for the 77401 then you cannot bill an e/m code.

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