I have just started billing for an Intra Operative Monitoring facility and after looking at some of the EOBS codes are being denied. The 95941 code is almost always denied by Aetna stating it is considered "experimental or investigational". We are not billing it with a modifier and I was hoping perhaps someone has had some experience, and a good outcome, of how to bill this code and get paid. The other codes that we bill are 95925 and 95926 with a 26 modifier and 95861 and 95812 with a 26 modifier.
Any information anyone has about billing these procedures would be greatly appreciated.
Thank you so much.
A couple of things... let's ignore the Aetna problems for now and first work with the coding situation.
+95941 is an add-on code, so a modifier would be unnecessary. However, you'd need an appropriate primary code to attach it to; +95941 cannot be billed alone.
The parenthetical notes say (Use 95941 in conjunction with the study performed, 92585, 95822,
95860-95870, 95907-95913,
95925, 95926, 95927, 95928, 95929, 95930-95937, 95938, 95939).
95925 and 95926 - these codes hit an edit in which 95926 will
always be bundled into 95925 and no modifier is allowed. There is code 95938 with both upper and lower limbs, but from what you've stated, there was only an interpretation of 95926 so I don't think that combo-code will work.
If you bill 95925, 95926-26, +95941; 95926 will deny for bundling and +95941 will attach to 95925. Now, if 95925 gets denied for non covered or experimental, then +95941 will also deny as it's the add-on.
If you bill 95861, 95812-26, +95941; the only code that +95941 will attach to is 95861. Again, if 95861 denies, +95941 will also deny.
Now Aetna... they have quite a few policies regarding most of these codes. Usually Aetna denies charges as "experimental" when they don't meet the criteria listed in their policies.
http://www.aetna.com/cpb/medical/data/100_199/0181.html
http://www.aetna.com/cpb/medical/data/600_699/0697.html
If you want some help working through those policies, I'd be more than happy to lend a hand.