Wiki Aetna for Allergy & Immunotherapy

[shain.mastroianni@allergyasthmaclinicltd.com]

Aetna is denying out Allergy testing (95004) stating that it is "incidental to the primary procedure code" The primary procedure code is 99213 with modifier 25 and has different diagnosis codes on it than the testing does. Is anyone else seeing this? How do you fix it? We have sent in records and it is still is denying. Please help

 

[lfontanez]

When are you sending in the claim for the new patient visit? Aetna guidelines are that you cannot bill another OV within 30 days of the new patient visit. Even if you are performing a different service. Like, if you did environmental testing on the 1st visit and then food testing 2 weeks later - 95004 is ok but they do not allow the OV. Same with biologic injections.
--Even though the Dr time is completely justified because they spent separate times on separate days for a different medical condition.

 

[shavird@onyxsc.org]

Our practice has recently been receiving payment from Aetna/Aetna Medicare for the E & M, but they are denying the allergy testing codes (95004, 95024). This is for an established OV and the provider has documented their time spent "outside" of the allergy testing. Are we not allowed to use the same code for the OV as we do for allergy testing? They automatically deny our reconsideration even with supporting documentation and they have to go straight to appeal.

 

[shain.mastroianni@allergyasthmaclinicltd.com]

When are you sending in the claim for the new patient visit? Aetna guidelines are that you cannot bill another OV within 30 days of the new patient visit. Even if you are performing a different service. Like, if you did environmental testing on the 1st visit and then food testing 2 weeks later - 95004 is ok but they do not allow the OV. Same with biologic injections.
--Even though the Dr time is completely justified because they spent separate times on separate days for a different medical condition.

Oh wow, I was unaware of this. Thank you so much for your help! I greatly appreciate you!

 

[shain.mastroianni@allergyasthmaclinicltd.com]

Our practice has recently been receiving payment from Aetna/Aetna Medicare for the E & M, but they are denying the allergy testing codes (95004, 95024). This is for an established OV and the provider has documented their time spent "outside" of the allergy testing. Are we not allowed to use the same code for the OV as we do for allergy testing? They automatically deny our reconsideration even with supporting documentation and they have to go straight to appeal.

I do not use the same DX codes on the OV as I do on the testing.

 

[lfontanez]

They, Aetna, sees it as a bundled service. So, if you've billed for an OV and a ST and then the patient comes back within 1 month for another ST and you also bill an OV, then they will deny either OV or ST. In the past, they've denied one or the other for us. I've been around and around with them on this. Even if we supply documentation that 2 completely separate visits and testing are performed, different ICD-10 codes, etc. - they still deny. We just don't code for an established f/u appt with repeat ST within the 1 month time frame.