Billing IOM

l!am2013

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I have just started billing for an Intra Operative Monitoring facility and after looking at some of the EOBS codes are being denied. The 95941 code is almost always denied by Aetna stating it is considered "experimental or investigational". We are not billing it with a modifier and I was hoping perhaps someone has had some experience, and a good outcome, of how to bill this code and get paid. The other codes that we bill are 95925 and 95926 with a 26 modifier and 95861 and 95812 with a 26 modifier.

Any information anyone has about billing these procedures would be greatly appreciated.

Thank you so much.
 
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I have just started billing for an Intra Operative Monitoring facility and after looking at some of the EOBS codes are being denied. The 95941 code is almost always denied by Aetna stating it is considered "experimental or investigational". We are not billing it with a modifier and I was hoping perhaps someone has had some experience, and a good outcome, of how to bill this code and get paid. The other codes that we bill are 95925 and 95926 with a 26 modifier and 95861 and 95812 with a 26 modifier.

Any information anyone has about billing these procedures would be greatly appreciated.

Thank you so much.

A couple of things... let's ignore the Aetna problems for now and first work with the coding situation.

+95941 is an add-on code, so a modifier would be unnecessary. However, you'd need an appropriate primary code to attach it to; +95941 cannot be billed alone.
The parenthetical notes say (Use 95941 in conjunction with the study performed, 92585, 95822, 95860-95870, 95907-95913, 95925, 95926, 95927, 95928, 95929, 95930-95937, 95938, 95939).

95925 and 95926 - these codes hit an edit in which 95926 will always be bundled into 95925 and no modifier is allowed. There is code 95938 with both upper and lower limbs, but from what you've stated, there was only an interpretation of 95926 so I don't think that combo-code will work.

If you bill 95925, 95926-26, +95941; 95926 will deny for bundling and +95941 will attach to 95925. Now, if 95925 gets denied for non covered or experimental, then +95941 will also deny as it's the add-on.
If you bill 95861, 95812-26, +95941; the only code that +95941 will attach to is 95861. Again, if 95861 denies, +95941 will also deny.

Now Aetna... they have quite a few policies regarding most of these codes. Usually Aetna denies charges as "experimental" when they don't meet the criteria listed in their policies.
http://www.aetna.com/cpb/medical/data/100_199/0181.html
http://www.aetna.com/cpb/medical/data/600_699/0697.html

If you want some help working through those policies, I'd be more than happy to lend a hand.
 

l!am2013

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Thank you danskangel313 for your response. I am replacing someone that is no longer with the company and I'm finding so many different ways she billed services.
We are billing either 95925 or 95926, depending whether we tested upper or lower and 95861 and then billing 95941 as an add-on code. We are billing the 95925/95926 and 95861 with a 26 modifier should we be adding the modifier? On claims I found that were billed to Aetna they will add on the 26 modifier, if we didn't add it on the claim.
I just found today that on claims UHC denied the 95941 she was sending in corrected claims replacing the 95941 with HCPCS code G0453, that is a Medicare code. Until I talk to UHC I don't know if they told her to bill that code or what the reason behind her billing that HCPCS code is.

As far as help with the Aetna policies regarding the codes I will gladly accept your help. Perhaps we can set up a convenient time, I'm pretty covered up at the present trying to unravel a lot of problems but I definitely will take you up on your offer.

Thank you so much!! :)
 
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Just send me a PM ahead of time and we'll set something up. And if you have a couple of specific coding examples (just the CPTs), include those if you can.
 

l!am2013

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I will PM you as soon as I can. It may be on the weekend or after 5:00 pm EST is that a problem?

Thank you again.
 

k_rae22

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Thank you danskangel313 for your response. I am replacing someone that is no longer with the company and I'm finding so many different ways she billed services.
We are billing either 95925 or 95926, depending whether we tested upper or lower and 95861 and then billing 95941 as an add-on code. We are billing the 95925/95926 and 95861 with a 26 modifier should we be adding the modifier? On claims I found that were billed to Aetna they will add on the 26 modifier, if we didn't add it on the claim.
I just found today that on claims UHC denied the 95941 she was sending in corrected claims replacing the 95941 with HCPCS code G0453, that is a Medicare code. Until I talk to UHC I don't know if they told her to bill that code or what the reason behind her billing that HCPCS code is.

As far as help with the Aetna policies regarding the codes I will gladly accept your help. Perhaps we can set up a convenient time, I'm pretty covered up at the present trying to unravel a lot of problems but I definitely will take you up on your offer.

Thank you so much!! :)

This is my first time on the forum. Did you figure out how to bill IOM to Aetna & UHC? I am having the same exact issues. We were billing 95941 without a modifier. I was going to try billing G0453 to UHC to see if that works. I am new to IOM billing, so any advice would be helpful. Thank you.
 
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