Aetna recently expanded its Claim and Code Review Program, which results in the downcoding of certain level 4 and 5 evaluation and management (E/M) claims. In late March, the program was expanded from the initial 12 pilot states to all Aetna commercial states except Louisiana. Further expansion to Aetna Medicare Advantage plans is planned for later this year.
The program scrutinizes level 4 and 5 E/M claims for “correct coding” and performs prepayment edits as the payer deems appropriate. This results in certain claims being paid at a lower rate than originally billed. Because there will not be a separate notification when claims are downcoded, practices are advised to monitor remittance documents for appropriate reimbursement.
Inclusion in the program generally lasts for one year; however, practices can pursue early removal from the program by successfully appealing 75% of downcoded claims. Additional information about the program is available in Availity, Aetna’s provider portal.
What Providers Should Know
The ACR is concerned about the inappropriate reduction of payment for rheumatology services and the burden on practices to review and appeal the downcoded claims. The ACR has engaged Aetna leaders to discuss these concerns as well as the general lack of transparency around the program’s criteria and operation. Members who have been impacted by this program are encouraged to reach out to ACR at [email protected] for assistance with claims review.
To help avoid inclusion in the program and ensure appropriate reimbursement from Aetna and other payers, ACR members are encouraged to always verify benefits before each visit, as coverage and policies may change in between visits. Additionally, it is important for providers to code and bill the highest level of specificity for diagnoses and ensure proper documentation in the medical record. The overuse of unspecified ICD-10 codes and inadequate documentation can result in downcoding, which can impact reimbursement in rheumatology practices.
To help ensure proper claim processing, providers should:
- Use the most specific ICD-10 codes to support clinical findings. Unspecified codes should only be used if there is no other relevant diagnosis code available;
- Document clearly and thoroughly to support the level of service billed; and
- Ensure medical necessity is met for the visit and supports the services rendered.
Members can stay up to date with an ACR one-hour lunch-and-learn session, which provides updates on the ever-changing coding and billing guidelines. To schedule a training session, contact Melesia Tillman at [email protected] and reserve your spot.
The American Medical Association (AMA) has also developed resources to assist practices in the fight against inappropriate downcoding. AMA guidance on payer E/M downcoding programs provides information and tools to assist practices in recognizing and fighting downcoding and help ensure payment for downcoded claims, even after the fact.
The ACR Insurance Subcommittee (ISC) engages with health insurance payers on behalf of the ACR and its members, routinely addressing concerns about reimbursement and administrative burden while ensuring continued access to critical therapies for rheumatic disease patients. For more information about the issue above or to request ISC assistance with another payer issues impacting your practice, reach out to [email protected].
