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Aetna Code Edits and Claim Payment Policy for Modifiers 59 and 81


Modifier 59 exceptions

Effective March 1, 2011, Modifier 59 will not override the following incidental edits/code combinations:

92502 when billed with 30000 - 31615 (nose, accessory sinuses, larynx, trachea)

92502 when billed with 40490 - 42972 (lips, vestibule of mouth, tongue and floor of mouth,dentoalveolar structures, palate and uvula, salivary gland and ducts, and pharynx, adenoids, and tonsils)

92502 when billed with 69000 - 69979 (auditory system)

45990 when billed with 45000 - 45999 (rectum) and 46000 - 46999 (anal)

57410 when billed with 56405 - 58999 (female genital system)

94150 - Vital capacity, total

94250 - Expired gas collection, quantitative, single procedure

94690 - Oxygen uptake, expired gas analysis; rest, indirect

94760 - Noninvasive ear or pulse oximetry for oxygen saturation; single determination

94761 - Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations

Modifier 81 – Minimum Assistant Surgeon

Effective March 1, 2011 When Modifier 81 is billed and the procedure is considered eligible for use of an assistant surgeon, Modifier 81 will be paid at 12 percent of the recognized charge/surgical fee allowance or the negotiated rate.

Reference: http://www.aetna.com/provider/data/OLU_SE_DEC2010_v4.pdf

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