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Billing Aetna injections with 20611 for ultrasound guidance.

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Can anyone offer any insight on billing injections for Aetna with 20611 for ultrasound guidance? Aetna denies 20611 every time per their policy that it's experimental. We have had some success with medical necessity on appeals, but Aetna Medicare has been denying this as well. Our sports medicine physician only does Orthovisc/Euflexxa injections with ultrasound. We are considering the option of billing the J code for the drug to Aetna and making the administration code self pay for the patient. Does anyone have any experience with this?
 

pscanlan

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For one service my providers bill now, TAP blocks, we bill two codes in direct contradiction of Correct Coding Initiative suggested methods. 64486 for the TAP block and 76942 for the guidance. 64486 specifically is inclusive of guidance. Now, most payers pay the 64486 line and remark/writeoff the guidance code as unbundling, but some pay on each line (for about as much total as other payers pay on the one line). I can't speak to which payers specifically as I mostly code now, and payment posting was never my specialty. What I'm getting at is that your code may be a similar situation, in that two codes may be preferrable for the payer for whatever reason. Maybe they track payments disbursed by the type of service, and they separate out ultrasonic guidance from surgical procedures, for example.

Perhaps there is an Aetna CPB covering this situation? Or maybe you could call Aetna and get through to a claims auditing manager to find out if they have a preferred format? Sorry that wasn't much of an answer, but at least there are still some paths forward besides just blindly appealing each denial. I would start by trying to find the relevant clinical policy bulletin, as that's what the Aetna claims reps are going to tell you to do if you speak to them first.
 
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Thanks. Yes, Aetna's CPB for this states that ultrasound-guided injection is not covered since they consider it experimental. My question is whether we can bill the insurance for the drug and the patient for the administration of the injection. This would be similar to DMEs that are not covered by insurance; we bill the office visit to the insurance and the patient pays out of pocket for the DME. I'm wondering if we can do the same and bill the J code to the insurance and have the patient self-pay for 20611.
 

dtricia

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20611 being done by the CMA

Is this within the Scope of Practice for a CMA? I looked in up on the California website and could not find anything about Ultrasound, just the injection.
I am looking at this procedure for the first time and this is the note I am looking at. It is signed by the CMA, not the MD.
Tricia D
 
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Firstly you cannot bill 20611 if the policy states they do not pay for ultrasound guidance. I believe you can just bill the 20610 for the actual injection.

As far as the Injectable drugs, you will need to review the AETNA policy to see if they are covered. If it is, you should be billing the insurance for the drug used. If it is not covered, bill the patient after having them sign an ABN.
 

ACord

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NCCI Guidelines on Splitting Charges

We recently looked into this sitation as our doctors wanted to also split up the drug from the arthrocentesis codes, such as for a non-covered drug. AAOS Now published an article in October 2018 stating the following:

Question: There is a lot of confusion in our office when the doctor injects viscosupplementation and it is not covered by a plan. The physicians want to report code 20610 to the payer for the injection and have the patient self-pay for the drug. Our billers do not believe this practice is correct and think the entire service should be self-pay—drug and injection. If you agree with the billers, is there anything we can use to convince our surgeons that they should not be billing the payer for the injection?
Answer: This is a frequent question that reveals confusion regarding appropriate coding. We agree with the billers. When the payer indicates that a drug is experimental or not considered “reasonable and necessary” and, therefore, is not covered, why would one think it okay to bill the mode of administration of the uncovered drug? There is documentation to support this line of thinking in the Medicare Carrier Manual: 50.4.3 Examples of Not Reasonable and Necessary. It says, “If a medication is determined not to be reasonable and necessary for diagnosis or treatment of an illness or injury according to these guidelines, the Medicare administrative contractors (MAC) that process Part A and Part B claims (A/B ) or durable medical equipment excludes the entire charge (i.e., for both the drug and its administration). Also, MAC A/B (B) exclude from payment any charges for other services (such as office visits), which were primarily for the purpose of administering a noncovered injection (i.e., an injection that is not reasonable and necessary for the diagnosis or treatment of an illness or injury).”

Based upon the above, I personally would not recommend to the provider that they downcode the 20611 to 20610, or split up the coding and bill separately. I would bill all codes to either the insurance company or the patient. If this is Medicare, the patient could sign an ABN prior to services so that you could attach the GA modifier to the charge(s). Something similar could be set up for private or commercial payors with a waiver. If the patient would like for you to file to see "if the insurance pays" and you recieve a denial, if you have collected prior to services being rendered, you should not have to pursue additional payment from the patient. I hope this helps!
 
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