03/29/2023

Aetna Denial for E&M and Injection with Modifier 25

we billed visit and injection (over 90 days from last visit) with a 25 modifier. Aetna denied the injection stating is considered incidental to the 99213 and since the RUV is higher for the 99213 they only paid that code. Is this correct? how can i get paid on the visit and injection?

To get paid for the office visit and the procedure, an appeal would need to be filed with Aetna. Even with distinct diagnosis codes and proper use of modifier -25, Aetna will commonly deny lesser procedures without supporting documentation. A post service appeal will need to be filed with the office notes to show that both an E&M code and minor procedure should be reimbursed for the DOS. This is a burden required on both commercial and Medicare Advantage claims, and the only way to get a partially denied claim reconsidered for additional payment.