bharmon518
New
I have a claim where 13160 was billed with a 58 modifier after surgery. Provider did a late closure of the wound in the office setting. Aetna denied stating "following CMS guidelines" it cannot be billed in the professional setting, but I see nothing in Codify/CMS/otherwise that states it can't be billed in the professional or outpatient setting. I see commercial payers, including Aetna, as well as Medicare also paying for a complex wound repair in the office setting as well, which I see little difference as they contain similar elements in the procedure. Has anyone come across this issue or successfully appealed/done a second level appeal? Thanks!