Modifier 26 - healthcare and aetna

[ACADIENTE]

How do I get an xray with modifier 26 paid...by united healthcare and aetna? All other insurances are paying but uhc and aetna. why is that?

Example...

99203
73030-26

 

[mitchellde]

How do I get an xray with modifier 26 paid...by united healthcare and aetna? All other insurances are paying but uhc and aetna. why is that?

Example...

99203
73030-26

What is the denial reason? Where was the X-ray performed? Did your provider perform the official interpretation or is this an overread? Do you have a separate interpretation report?
I order to use the 26 modifier, your provider must perform the official radiology interpretation with a separate report note. This is not a sentence in the progress note. If this was done in say an outpatient facility and the facility billed for the technical and the interpretation then your provider cannot bill with the 26.

 

[ACADIENTE]

What is the denial reason? Where was the X-ray performed? Did your provider perform the official interpretation or is this an overread? Do you have a separate interpretation report?
I order to use the 26 modifier, your provider must perform the official radiology interpretation with a separate report note. This is not a sentence in the progress note. If this was done in say an outpatient facility and the facility billed for the technical and the interpretation then your provider cannot bill with the 26.

Physician Assistant's claim

99204

Payment has been made in accordance with an agreement with Medical Data Exchange. The Member is not responsible for any payment beyond the applicable co-payment, coinsurance or deductible requirements noted.​

73030-26

This procedure or supply is part of the global service. These charges are not eligible for separate reimbursement.​

Physician's claim
73030-TC ---Paid

Diagnosis for both claims are 726.0 and 719.41

On PA's medical notes, there are notes supporting the office visit.

Under Xray: Indication: PAIN. Xray interpretation: standard 4 view x-ray series of the right shoulder read by me demonstrates no acute osseous injury. No complications. No other views were needed.


So basically, we billed 26 for the xray read by a PA. Then we billed TC for utilizing the xray machine own by an MD.

Is there a way to appeal for this? Medicare pay these kind of claims with no problems at all. I'm frustrated with United Healthcare and aetna.

 

[stephanie7480]

Are you sure it isn't bundling to the E/M.
I would try adding a 25 to the E/M on the PA's claim.

 

[mitchellde]

You might check with the PA licensing in your state and with your Medicare region. Many do not allow a PA to provide an official radiology interpretation. They are bundling into the E&M. If you have an interpretation report separate from the E&M and if the PA is allowed to provide the official interpretation then appeal with the office note and the interpretation report.
The note you provided is not an official radiology interpretation report. This cannot be a blurb in the office note it must be its own stand alone report.

 

[ACADIENTE]

Are you sure it isn't bundling to the E/M.
I would try adding a 25 to the E/M on the PA's claim.

Ok, I will try that. Thank you.

 

[ACADIENTE]

You might check with the PA licensing in your state and with your Medicare region. Many do not allow a PA to provide an official radiology interpretation. They are bundling into the E&M. If you have an interpretation report separate from the E&M and if the PA is allowed to provide the official interpretation then appeal with the office note and the interpretation report.
The note you provided is not an official radiology interpretation report. This cannot be a blurb in the office note it must be its own stand alone report.

Ok, thank you for your advice.

 

[mderemer]

To bill for the original radiology interpretation, it must be a separate report, and there can't already be an official interpretation by a radiologist. If this x-ray was done at an outside faciity, the radiologist on staff there most likely has already perfored the officeal, original interpretation. If your provide is just making comments, that would be included in the level of E/M service.