Coding

  • 1.  Aetna Denial 76813

    Posted 04-10-2023 23:21

    Hi everyone, 

    I recently started getting Aetna denials on 76813 (nuchal translucency) due experimental for every patient. Even if the patient has a positive NIPTS test. Has anyone else experience this and any ideas of which dx are covered?

    These are the diagnosis that I have tried based on patient medical records. 
    - Z36.82 (this diagnosis has been paid in the past)
    - O36.80X0
    - O28.1 (this diagnosis has been paid in the past)
    - Z36.9 (this diagnosis has been paid in the past)
    - O28.5


    Any insights would be helpful. Thank you!



    ------------------------------
    Areesa Twaheel
    ------------------------------


  • 2.  RE: Aetna Denial 76813

    Posted 04-11-2023 17:49

    Hi Areesa! Aetna changed their policy around this within the last year, located here: https://www.aetna.com/cpb/medical/data/200_299/0282.html 

    Kimberly



    ------------------------------
    Kimberly Montero
    ------------------------------



  • 3.  RE: Aetna Denial 76813

    Posted 04-12-2023 22:19

    Thank you!



    ------------------------------
    Areesa Twaheel
    ------------------------------



  • 4.  RE: Aetna Denial 76813

    Posted 04-11-2023 18:49

    Hi Areesa, 

    This is a common question, thanks for asking.

    The Aetna payment policy concerning this issue can be found here: https://www.aetna.com/cpb/medical/data/200_299/0282.html

     According to their policy, Aetna will reimburse for first and second trimester screening services in the following circumstances:

    ·         First-trimester nuchal translucency (NT) testing alone (without serum analyte screening) for multiple gestations; or

    ·         First-trimester NT measurements results combined with the results of first trimester serum analyte tests that include pregnancy-associated plasma protein A (PAPP-A) plus beta-human chorionic gonadotropin (hCG)footnotes*; or

    ·         Integrated, sequential, or contingent screening: First-trimester triple test (NT, PAPP-A, and hCGfootnotes*) plus second-trimester quadruple test (maternal serum alfa-fetoprotein (MSAFP, unconjugated estriol, inhibin A, and hCGfootnotes*) screening; or

    ·         Second-trimester serum analyte screening (see CPB 0464 - Serum and Urine Marker Screening for Fetal Aneuploidy); or

    ·         Serum integrated screening for pregnancies where NT measurement is not available or cannot be obtained: First-trimester (PAPP-A plus hCGfootnotes*) plus second-trimester quad (MSAFP, uncongugated estriol, inhibin A, and hCGfootnotes*) screening; or

    ·         Measurement of cell-free fetal nucleic acids in maternal blood when criteria are met in CPB 0464 - Serum and Urine Marker Screening for Fetal Aneuploidy.

    According to their policy:  Aetna considers the above-listed screening tests for fetal aneuploidy not medically necessary for women who have previously had a microarray or non-invasive prenatal testing (NIPT) with cell-free DNA during the current pregnancy.

    The nuchal translucency service is clearly not "experimental," but Aetna uses that terminology to communicate that they will not pay for the service if it is not compliant with the payment policy that they have established.

     

    Please refer to the SMFM Coding Committee's White Paper on this topic, which is found at https://www.smfm.org/coding/white-papers/221-billing-scenarios-for-imaging-and-aneuploidy-screening-in-the-first-trimester-replaces-oct-2017-white-paper.

     While not a clinical recommendation, from a reimbursement perspective the nuchal translucency is payable only when it is performed before the non-invasive prenatal testing (NIPT).

    Hope this is helpful, 

    Manijeh



    ------------------------------
    Manijeh Kamyar
    ------------------------------



  • 5.  RE: Aetna Denial 76813

    Posted 04-12-2023 22:18

    Thank you for the update. I am aware of the policy however, they were paying my claims up until November of 2022. 



    ------------------------------
    Areesa Twaheel
    ------------------------------



  • 6.  RE: Aetna Denial 76813

    Posted 04-12-2023 17:33

    Yes, for all my providers cpt 76813 is now being denied as experimental and the only way we've been able to get them paid is to do appeals for each denial. They will get paid eventually just a process. Pls let me know if you need help with the appeal process. 



    ------------------------------
    Galina Tulman
    ------------------------------



  • 7.  RE: Aetna Denial 76813

    Posted 04-12-2023 22:17

    Hi Galina.

    would you be able to share a sample of what your appeal looks like? or anything that would help me with the appeal? Your help is greatly appreciated!

    Thanks,
    A. Twaheel



    ------------------------------
    Areesa Twaheel
    ------------------------------