Wiki Aetna denial for CPT code 25116 & 29844 on same day of service

[shortee3810]

I have a surgery denial of CPT code 25116 (dorsal tenosynovectomy) and 29844 (arthroscopic synovectomy) as mutually exclusive to 25320. When reading the description of 25320 it states "including synovectomy" therefore can understand the possibility of denial. However, CPT code 25116 I do not understand the denial since the CMS NCCI edits allow a modifier to be appended. There was a separate incision thus the reason for appending 59 modifier. By the way this is Aetna Insurance that is denying. Help! Any insight.

 

[A51080]

My advice would be to call Aetna and see if this is a payor specific edit that when those CPT codes are billed together they consider it bundled. There are several payors that have their own edits and do not follow CMS NCCI edit guidelines. Since it was a separate incision you can try submitting a reconsideration along with the op report and an explanation as to why they should process 25116 as a separate billable procedure? Hope this helps.

 

[Orthocoderpgu]

If both procedures were dorsal your probably not going to get very far. If they were on opposite sides, you may have a case. My pet name for 25320 is "Kitchen Sink" since just about everything is included with it. Look at the RVU's compared to other procedures. So not surprising that insurance would bundle procedures into it. Good luck.

 

[fwnewbie]

If both procedures were dorsal your probably not going to get very far. If they were on opposite sides, you may have a case. My pet name for 25320 is "Kitchen Sink" since just about everything is included with it. Look at the RVU's compared to other procedures. So not surprising that insurance would bundle procedures into it. Good luck.

LOL Kitchen sink huh? That's awesome!!