01/11/2017
Aetna Denial for 11055 and 11719 with E11.59
Aetna denied payment for 11055 q9 when billed with 11719 59 q9. Diagnosis code E1159 was used with both. 11719 59 q9 was paid. Do you Nile explanation was "this service does not meet the coverage requirements in the applicable local coverage determination open parenthesis LCD) or national coverage determination (and CD) related services performed in connection with the denied procedure also not covered the members not responsible for this charge. what did I do wrong? Should I have used Cut or xs modifier with the 11719 q9? Last seen date was listed as 11/16/2016. My date of service for the patient was 12/15/2016. Thank you, Hoda!
The only way the claim would be denied for medical necessity would be for frequency - if the patient was seen within 62 days for routine foot care services, the charges could be denied for medical necessity.
The diagnosis reported (E11.59) is medically necessary as a systemic condition for routine foot care per NGS Medicare, which should be Aetna’s reference for medical necessity requirements for the service. The modifiers submitted with the nail trimming are also appropriate and should not cause the service to be denied.
If services were rendered more than 62 days apart from the last time the patient received RFC services, a call to Aetna should be made requesting them to adjust the service since it is medically necessary per NGS LCD ID L33636 - an appeal may be necessary with the medical policy if customer service will not send the line back for an adjustment to pay.