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Wiki Coding against Yearly limits IE capped for testing

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rbordes

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I am interested in allergy testing, if a commercial plan has a 365 day cap of 40, medicare allows 90 when properly coded and documented is there a way to code to allow for additional tests? i.e. Aetna caps 40 for 365 days, is it possible to overcome this limit? Would a Xu, Xe or -59 on line 2 after line 1 with 40 units is place overcome this?
 
There is no code or modifier that is designed for this purpose - coding systems are created to represent services performed, not to give providers ways of bypassing insurance payment limitations. You might try reading through the payers' published policies to find out if there are specific circumstances where they will override the caps and pay and see if they have guidelines on how they expect the claim to be submitted for those cases. But otherwise, although it may be possible to find a way of coding that will allow the excess units to bypass the payer's detection, ultimately this will not serve well in the long run because it will likely be identified during post-pay audits and then the payments will need to be refunded or recovered.
 
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