Aetna Clinical Payment, Coding and Policy Changes

January 2018 ~

Aetna has made adjustments to five clinical payment, coding policies that will become effective on March 1^st.

• Expanded Claims Editing – claims editing capabilities will be expanded by adding a new third party claims editing solution. This will allow Aetna to enhance its prepayment claims editing processes for clinical payment and coding policy rules and improve accuracy for existing edits and add new claims edits.
• Multiple Procedure Reduction For Diagnostic Cardiology Services – the allowable amount of multiple diagnostic cardiology services will be reduced by 25%. This change does not apply to the service with the highest relative value units (RVU) rate. This change applies to the technical component (TC) of the RVU only, for:
  • Services on the same date of service
  • Services billed by a single provider
  • Services billed for the same patient
• Multiple Procedure Reduction For Diagnostic Ophthalmology Services – the allowable amount of multiple diagnostic ophthalmology services will be reduced by 20%. This change does not apply to the service with the highest RVU rate. This change applies to the TC of the RVU only, for:
  • Services on the same date of service
  • Services billed by a single provider
  • Services billed for the same patient
• Multiple Procedure Reductions For Therapy Services – multiple procedure reductions will be applied to certain therapy services. Aetna will pay 100% of the therapy service the highest practice expense (PE) RVU. The PE RVU portion of the total RVU will be reduced by 50% for more therapy services performed on the same day.
• Correct Coding Of Hospital Observation, Critical Care, and Admission And Discharge Services – In September, Aetna stated that, effective December 1^st, 2017, they would limit coverage for hospital professional services to once per day, per patient across all providers. The insurer has instead decided that it will not apply the policy to critical care services (99291-99292). As well, Aetna says it will not apply the policy to hospital admission services (99221-99223) for nonparticipating providers for its Medicare Advantage plans.
• Payment and Coding Policy Changes – Aetna’s standard payment policies does not reimburse services that are considered incidental to the overall episode of care. This includes supplies, materials and equipment such as:
  • Sutures or suture substitutes
  • Dressings • Syringes
  • Gauze
  • Catheters
  • Guide wires
  • Stationary devices
  • Parenteral infusion pumps
• Aetna notes that beginning March 1^st, the Healthcare Common Procedure Coding System (HCPCS) codes C2617, C2625, C1752, C1769, C1770, C2623 and C1884 will be considered incidental. There will be no additional payment for these items.

Source(s): Aetna OfficeLink Updates™- All Regions;