Wiki Facility vs Professional

[cpc05]

Hello,
Aetna Medicare has started denying claims stating the facility has already billed for the same procedure (colonoscopy CPT 45385). Our provider performed the colonoscopy at an ambulatory surgery center. Our claim was denied as maximum number of service billed on the same day. The facility submitted their claim first and it was paid. Is anyone else having this issue and if so, how did you resolve it?

 

[Same Day SC]

I am assuming both the provider and the ASC are billing on a professional (HCFA-1500) electronic format. If so, be sure that the provider's NPI # is recorded on the line of the CPT code. The place of service will be 24 for both claims. This will differentiate the difference between the facility and the provider's claim.

 

[cpc05]

I am assuming both the provider and the ASC are billing on a professional (HCFA-1500) electronic format. If so, be sure that the provider's NPI # is recorded on the line of the CPT code. The place of service will be 24 for both claims. This will differentiate the difference between the facility and the provider's claim.

Yes, we are both billing on HCFA-1500 electronic format. All of these items are in place, but the claims are still being denied. Thanks for you help.

 

[Same Day SC]

Some payers in our state require an SG modifier to the CPT code.

 

[cpc05]

Some payers in our state require an SG modifier to the CPT code.

Thank you. I will look into this to see if the ambulatory surgery center staff is appending this modifier when appropriate.

 

[swisssmizz]

Our clinic is having this same issue and have been for years. We do use modifier SG but that doesn't help. We have spoke to our Aetna rep and they recognize there is an issue but are not addressing it. Our EOB's show benefits maxed and drop the entire balance to patient resp. We have had success in billing the patient then having them contact Aetna customer service and having it reviewed that way. Once they get involved what do you know we get payment.