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Xiaflex....ugh. HELP PLEASE!!!

  1. #11
    Default Xiaflex road blocks
    Medical Coding Books
    The Aetna policy that states they cover Xiaflex only addresses the drug and possibly the injection on the first day. They have since revised their Clinical Policy Guidelines for 'manipulation under anesthesia' to exclude the extension procedure used on day 2 - and they consider the 26989 -the unlisted code - under that policy. So that reimbursement has been effectively blocked as of 04/29/11 by Aetna.

    A shame, too, because I really feel it is a break through product for non-surgical treatment.

    The reps also urged us to bill 26989 both day one and day two. I feel that goes against the 'highest specificity'. 20550 does specify 'aponeurosis'. From hand anatomy I have researched the contracture is a persistent cord of fibrous (scar or otherwise) tissue that forms in the fascia or aponeurosis.

    If Aetna has already begun putting up roadblocks against reimbursement for components of the treatment proposed in the Xiaflex manual, I am certain that Humana (UGH!) will be fast on their heels.

    We had billed the injection, 20550, day one; and an E/M, 26989 on day two. We had all authorizations in place. Documentation could have been better, but was sufficient. Still waiting for the first reimbursement for a 26989 in month 13!

    The comp code we did use for the 26989 was for manipulation under anesthesia which I clearly appealed was due to work RVU references alone and that the 26989 did not actually represent 27430 (otherwise we would have billed it) because the joint was not manupulated, but the extension of the weakened cord was performed.

    I will keep you posted on further developement.

  2. #12
    Piedmont Area Coders, VA
    THANK YOU THANK YOU!! I so appreciate your feedback! I am glad I am not the center struggling to get reimbursed.....

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