CPT 30140 being paid at the facility rate when done in the office

[ldavis@myents.com]

We are having an issue with Aetna paying for CPT 30140 at the facility rate regardless of where the surgery is performed. At times we do this surgery in our office with POS 11 however Aetna continues to pay this at the facility rate instead of the professional rate. Can anyone help me understand why this is being done? Aetna cannot explain why they are paying our claims that way. Any and all help appreciated.

 

[catherinetinkey@entmedicalservices.org]

Do you know what your fee schedule is and is this a stand alone procedure or done with other procedures. Aetna's reimbursement is awful and lots of their commercial plans reimburse at Medicare rate or little above, for Medicare there really isn't much difference between facility and office for this code. They still should be reimbursing the office fee not the facility fee. I would review your fee schedule and any policies they have on that code then call and try to get a supervisor to review it.

 

[csperoni]

Agree with @catherinetinkey@entmedicalservices.org. This is dependent on your contract and fee schedule.
I worked for a practice that had a surgical suite to perform minor procedures in the office. For some procedures/some payors, they would not pay any site of service differential, even if the RVUs were different based on location.