Wiki Help please! Aetna denying 95004 for RVU

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shavird@onyxsc.org

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We have recently been receiving denials from Aetna when we bill an E&M with allergy testing. The patient is coming in for a follow-up visit after trying conservative measures and the decision is made to do testing. They will reimburse the E&M but deny 95004 (allergy skin testing) as incidental. Since this is a follow-up visit, there are also other issues discussed. We do not bill the same diagnosis code for the E&M and the testing code. When appealed, they referenced that the RVU for an E&M is higher than for allergy testing code. I can't seem to find any information to prepare for appeals that deals with this specifically. There is information about when a payer denies the E&M but none for denials on the testing codes for RVU. Any help would be most appreciated!
 
shavird@onyxsc.org said:
We have recently been receiving denials from Aetna when we bill an E&M with allergy testing. The patient is coming in for a follow-up visit after trying conservative measures and the decision is made to do testing. They will reimburse the E&M but deny 95004 (allergy skin testing) as incidental. Since this is a follow-up visit, there are also other issues discussed. We do not bill the same diagnosis code for the E&M and the testing code. When appealed, they referenced that the RVU for an E&M is higher than for allergy testing code. I can't seem to find any information to prepare for appeals that deals with this specifically. There is information about when a payer denies the E&M but none for denials on the testing codes for RVU. Any help would be most appreciated!
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Are you using a modifier on your E/M code? It wasn't clear from your post.

There is an NCCI edit for 95004 and 99212-99215. 95004 is the primary code in the pair, so you'd need a modifier on the E/M code to override the NCCI edit.

Normally a payer would pay only the primary code in the pair, which is 95004. Aetna is telling you that they allowed the E/M code instead, because you're getting paid more (higher RVU) than if they only paid the 95004.
 
Because when it's a new test, we generally test 80 units so that's a lot of money to leave on the table for that code and only be reimbursed for the E&M
 
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