Wiki J7325 denied as Missing/incomplete/invalid principal procedure code.

[Biller2023]

We billed J7325 and 20611 to Aetna Medicare with M17.12 (unilateral primary osteoarthritis, left knee) as the primary diagnosis for both of these CPTS and M25.562 (pain in left knee) as the secondary diagnosis, however Aetna Medicare paid for 20611 and denied J7325 stating Missing/incomplete/invalid principal procedure code & The related or qualifying claim/service was not identified on this claim.

How do we fix this denial?

 

[sls314]

We billed J7325 and 20611 to Aetna Medicare with M17.12 (unilateral primary osteoarthritis, left knee) as the primary diagnosis for both of these CPTS and M25.562 (pain in left knee) as the secondary diagnosis, however Aetna Medicare paid for 20611 and denied J7325 stating Missing/incomplete/invalid principal procedure code & The related or qualifying claim/service was not identified on this claim.

How do we fix this denial?

What is the reason for using M25.562 (pain in left knee) with M17.12 (osteoarthritis, left knee)? The pain is due to the osteoarthritis, is it not?

On the CPT codes, those look consistent with what my provider billed for me when I had knee injections last year. I'm not sure what to suggest for that.

 

[amyjph]

US guided is not allowed for Visco with Aetna I believe.
Was this Synvisc One?

You have to lookup the Aetna Medicare Viscosupplementation policy and Ultrasound Guidance policy. Your answers are there.

 

[Biller2023]

We injected synvisc and not synvisc one. Please see the attached. The top of the precert form says synvisc is preferred.

 

[amyjph]

We injected synvisc and not synvisc one. Please see the attached. The top of the precert form says synvisc is preferred.

Ok, but you still need to verify if they allow it to be done via US. (Aetna Medicare Viscosupplementation policy and Ultrasound Guidance policy)
Also agree with Susan on questioning coding a sign/symptom (pain) with the OA.
It could be incorrect diagnosis code linking, it could be incorrect modifier (was LT used correctly), it could be they don't allow US w/ Visco.
Remove the pain dx, check all modifiers, check all dx code links. If there were 2 dx codes on the claim, were both linked to each line item? The J code will not go through without the OA linked.