Aetna Code Edits and Claim Payment Policy for Modifier 59 and Modifier 81
Modifier 59 exceptions
Effective March 1, 2011, Modifier 59 will not override the following incidental edits/code combinations:
CPT 92502 when billed with 30000 – 31615 (nose, accessory sinuses, larynx, trachea)
CPT 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)
CPT 92502 when billed with 69000 – 69979 (auditory system)
CPT 45990 when billed with 45000 – 45999 (rectum) and 46000 – 46999 (anal)
CPT 57410 when billed with 56405 – 58999 (female genital system)
CPT 94150 – Vital capacity, total
CPT 94250 – Expired gas collection, quantitative, single procedure
CPT 94690 – Oxygen uptake, expired gas analysis; rest, indirect
CPT 94760 – Noninvasive ear or pulse oximetry for oxygen saturation; single determination
CPT 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
