Wiki Circs in facility only????

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Jessim929

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Hi All!

I don't know if Aetna is just being obstinate or if I'm missing something but my Peds division is getting denials from Aetna for circs done in the office, and they're being told that "Medicare guidelines state this is a facility-only code". Aetna will not state exactly what Medicare guideline says it or provide a written copy of it. I can not find anything that says 54161 is a facility-only code - not even on CMS.

Do they know something I don't?

Thanks!!
 
I saw that as well. And on Encoder Pro, RVUs are exactly the same for Facility and Non-Facility.
 
Dear Aetna:

(Blah blah identifying information)

You have denied code 54161 done in the office (POS 11) because you state, "Medicare guidelines state this is a facility-only code." We can find no such guideline to be in existence. Further, the Medicare fee schedule shows both a facility AND a non-facility price for this code (see attached). Codes that are facility-only do NOT have a non-facility price in the Medicare fee schedule. The prudent layperson could extrapolate that this means that Medicare does indeed cover this code in the office setting.

Please provide us with the exact Medicare guideline and source document that reinforces your position or reprocess and pay the claim.

Sincerely,
 
I agree. I believe Aetna is telling us they will only pay for an infanf circumcision in an office setting but not for a patient over 28 days old.
 
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