VISCO INJECTION DENIALS

Is anyone else having trouble with denials on visco injections from Aetna on the J code? The denial reason is, required or missing modifier. We have tried using modifier and not using modifier. They were paying without modifier but now all of a sudden they are denying all of them. We do a lot of those inject and we can't get answer from Aetna on what they want nor where to find it in their guidelines. They say they follow Medicare guidelines, however Medicare doesn't require modifier on j code, so we are at a loss. Any help would be appreciated. We are located in FL.

Comments

  • Our carrier, NGS (we are in NY), has an article related to their LCD L33394--Article A52420.  It tells us to use the EJ modifier on the J code.  See below--just copied and pasted.

    Coding information:

    1. If an aspiration and an injection procedure are performed at the same session, bill only one unit for CPT code 20610.
    2. The appropriate site modifier (RT or LT) must be appended to CPT code 20610 to indicate if the service was performed unilaterally and modifier (50) must be appended to indicate if the service was performed bilaterally.
    3. Use "EJ" modifier on drug codes to indicate subsequent injections of a series. Do not use this modifier for the first injection of each series. A series is defined as the set of injections for each joint and each treatment. Injection of the left knee or shoulder is a separate series from injection of the right knee or shoulder.

    I don't know if this is what your carrier wants as I know they each have their own instructions but thought I would share this in case it might be helpful.

    Donna


  • Not seeing anything in the Aetna policies but First Coast wants the Rt/Lt to indicate which knee is being injected.
  • Yes.  They will want the LT/RT on the injection code (20610) but not on the drug code. 

    loried, look at your denials to see if they are paying the first J code in the series.  If they are paying the first injection with no trouble, try putting the EJ modifier on the drug codes for the second and third to see what happens.  As we all know, many times insurance is terrible about giving us all of the information that we need to get claims paid correctly.  Keep us posted.  Thanks,  Donna

  • Thanks all, but I'm still not convinced. DonnaCuifolo, I see your LCD guidelines which are different from ours, why they all cant be the same, im not sure, but under your lcd you can do for knee and shoulder, we can only do for knee and we don't have any modfiers that are required in our LCD L33767 under FIRST COAST SERVICE OPTIONS, FLORIDA. This is strictly for the "J" code. The 20610 we use either RT OR LT OR 50 modifier, which we don't have a problem on.  I did check on my patients and this last batch of injections, they have denied them all, not just the 2nd or 3rd. So if they wanted "EJ" modifier, why did they deny the 1st one? DX Code is either M17.11, M17.12 or M17.0. If they use Medicare guidelines, and there are no modifiers listed under the LCD, why can they deny them? They did pay on the 20610 code. We do also use the "GA" modifier on the J code for the ABN, but again, this is for Medicare only. I just don't know why they were paying on "J" code and now they aren't. SO SO VERY FRUSTRATING!!! So again, any help would be appreciated and I thank you all for your responses!! Maybe, I'm just reading it wrong, but Ive been doing this for a long time and haven't had this much trouble!  
  • But maybe you are right and it is the "EJ" Modifier. Maybe they are reading another LCD and using that instead of ours for FL, assuming I'm right and no modifier is required. I will have to call them again and see what the next answer is, only thing is, they don't know the answer either!
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