Wiki Need help with a denial for 76942

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chase0702

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I'm needing help with a procedure that was denied..

Aetna denied 76942 (ultrasonic guidance) with mod 26 for a procedure on the knee. The provider did use a pain block 64448 and 64445 with mod 59. Could some body please help me with this and what I need to do to get this paid?

Aetna states that because this charge bills separately for the professional component of the radiology procedure, it does not meet theis coverage requirement.

What can I do to get this paid??
 
You would want to do a written appeal. If they deny your appeal, you could ask who your provider representative is and ask them to review the claim by calling them on the phone and see if they can "esculate" the claim to someone to do an additional review.
 
I have received similar denials from Aetna for code 76942. Our reconsideration was denied stating, "When a non-radiologist submits a claim for only the professional component of a radiology procedure, this service will be considered part of the overall evaluation and management of the patient and will not be reimbursed separately." Do I try another appeal? If so how should I go about appealing? Thanks!
 
I would see if they have medical policy. If not you can do a second appeal requesting, explanation so that you better understand Aetna's payment methodology for Ultrasound guidance procedures. Like Monitored Anesthesia Care for non-invasive pain procedures, when we were getting denials from Aetna they forwarded us a memo stating that they were not going to pay for it. I was just make the attempt at getting something in writing that is beyond just computer generated denial remark. Do the second appeal and once you show the physician or business manager a denial of second appeal and any correspondance you have received on the subject that is when you have provide the information to the physician, management, and you can work with them on how they want to handle the situation---continue performing for all carriers and accept the denials and adjust off. Or consider fluoro guidance for certain procedures.
 
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