Important Update on Aetna Denials for Indirect Ophthalmoscopy with Certain Glaucoma Diagnoses

As reported previously, Aetna had revised its Indirect Ophthalmoscopy with regard to codes 92225/92226. This revision allowed for certain glaucoma diagnosis codes under ICD-9.

However, even with this change, a number of claims had been denied for specific ICD codes (365.11, 365.13 et al) even when these codes were on the covered indications listing in the Coverage Policy Bulletin (CPB).

Apparently, the system was (1) not reading the diagnosis code range properly resulting in denials and (2) there was a lag period before these fixes found their way into the claims processing system as the policy was revised in August 2009 and the changes were implemented on November 24, 2009.

Contact was again made with senior staff at Aetna and, according to them, the glaucoma codes from 365.00 through 365.9 will now process through the claims system.

So if your practice received any denials for these codes for dates of service between the date the CPB was published on August 15, 2009 and the date the rule was changed in the system on November 24, 2009, they can be resubmitted and Aetna will allow them for payment.

As for the diabetes related ICD codes, physicians are reminded that if an Extended Ophthalmoscopy with retinal drawing is used to evaluate a diabetes related eye condition, an ICD code indicating the presence of the ocular manifestation (i.e. retinopathy) should be included on the claim as the primary diagnosis with diabetes as secondary if necessary.

Claims with just an ICD code for diabetes (250.xx et al) are general codes for diabetes and are not specific as to the presence of an ocular manifestation (retinopathy).

For guidance on this issue, contact us through the Third Party Insurance Help Program.

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James A. McNally, CPC

Health Care Consultant Services