Aetna Denied Claim for CPT Code Knee Injection Billing Code 20610 as Investigational

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billing 20610 denied as investigational knee injection billing coding code for oaSo here’s a question from one of my blog readers….

“Aetna rejected our claims for CPT 20610 (knee Injection) as “investigational”. Please let us know what we should do to make this claim get reimbursed.” ~ Barb from Florida Pain Practice

My Recommendation:

I have seen this denial so many times and what I have been advising the practice is by looking at Aetna’s Clinical and Reimbursement Policy. This is most likely due to your Diagnosis Code that does not meet the Medical Necessity guideline according to Aetna’s Policy.

You can call Aetna and ask them about their policy, I am very sure they will guide you and they will direct you with that policy. When you have the guideline and policy, review your documentation and medical necessity. You can submit then a corrected claim or appeal the claim if your Diagnosis Code is not listed in one of the diagnosis that meets necessity per their policy.

Let’s review the CPT 20610 changes in 2015..

Revised 20600 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance New Code 20604 with ultrasound guidance, with permanent recording and reporting (Do not report 20600, 20604 in conjunction with 76942) (If fluoroscopic, CT, or MRI guidance is performed, see 77002, 77012, 77021) Revised 20605 Arthrocentesis, aspiration, and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow, or ankle, olecranon bursa); without ultrasound guidance New Code 20606 with ultrasound guidance, with permanent recording and reporting (Do not report 20605, 20606 in conjunction with 76942) (If fluoroscopic, CT, or MRI guidance is performed, see 77002, 77012, 77021)

Revised 20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder hip, knee, subacromial bursa); without ultrasound guidance

Key Points:

  1. Report 77002 if it’s Fluoro-guided
  2. Report Unilateral Modifiers (LT, RT) or Bilateral (-50)
  3. Report Specific (anatomical site) Diagnosis Codes
  4. Report EM with Modifier 25 if distinct and separately identifiable E/M encounter, above and beyond
  5. Report the drug used for injection (HCPCS Code) when required
  6. Proper Documentation is the ultimate key

New Code 20611 with ultrasound guidance, with permanent recording and reporting (Do not report 20610, 20611 in conjunction with 76942)
(If fluoroscopic, CT, or MRI guidance is performed, see 77002, 77012, 77021)

 

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Author: Pinky Maniri

Ms. Pinky, as she is fondly called - is a Reputable Professional Consultant and Expert in Practice Administration, Medical Billing, Coding, Health Information Technology, Insurance Credentialing and Compliance for Physician Offices. Well-educated with a Degree in Computer Systems Engineering and a background in Clinical Nursing and Small Business Management. Her professional mission is to make sure her clients/physicians maximize reimbursement while they remain compliant with the current rules, changes, guidelines and policies. Read More About Ms. Pinky here and See what Other's say about her Expertise Testimonials

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