08/05/2021

Aetna Denial for I&D with Modifier 79

I billed Aetna for a fracture toe (S92.514a) 28510 on 5/21/2021. Patient returned for abscess L02.611 on 7/16/2021 and i billed 10060-79 -rt. I was denied for 90 day global. We called and were told that even though i used modifier 79 Aetna does not accept that modifier and they will not pay for any additional procedure within 90 days. Can they deny the modifier

If the I&D performed within the global period is not related to the fracture treatment, then a call to Aetna is recommended and if the documentation for both encounters show that the minor procedure is not related to the major procedure. The course to have this denial overturned would be to appeal the denial with the Aetna appeals form. Along with the completed form, the progress notes from both encounters, and supporting documentation, should be included to have the denial reviewed. The diagnoses codes for the two encounters should also be distinct- if there is any overlap between the two dates with the coding, even with modifier -79 appended to the I&D, Aetna will deny the minor procedure.