response - G0416 Aetna Medicare
Hi bbooks,
Working with Aetna Medicare can be a HUGE pain! When you review the explanation of benefits on your denial - who did they have listed as the service provider? Was it your facility instead of your pathologist? If so, this is a credentialing issue. G0416 wouldn't need any other codes. What is the complete list of adjustment codes provided on your EOB. I usually see three provided. Usually the first listed denial code makes you believe that you may be coding the claim incorrectly.
I know it's cumbersome but have you actually called them to inquire on what other procedural codes they feel "should be listed"? I was always humored to be told by them to ask your "coder" what is missing and I had the opportunity to explain that I was the coder and this is coded correctly so please explain what is being denied.
About 3 weeks ago, I actually had the opportunity to talk a representative at Aetna Medicare. The representative was super nice and kept reiterating the denial reasons listed on my EOB and I wasn't having that - I have already dealt with so many denials with this place I finally asked if my provider was in both of their systems. Yes, they have two systems the "main frame" system and a "secondary" system to match up claims with. All updates are completed to the main system but the secondary system doesn't seem to follow suit as it should with these necessary updates. (Note: when they do need to update the secondary system with the information from the main system it can take up to 30 business days but only when told to do so.)
Please pay attention to the second adjustment code, that may be your key?? Please take the time to do that 30-40 minute call and talk about the denial with them to find out what is happening. If your facility is listed as the service provider instead of your pathologist ~ it's possibly a credentialing issue.
I am wishing you tons of success fixing this for reimbursement!!!
Thanks for listening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB