Aetna Issues ASC and Ambulatory Payment Classification (APC) Code Edit Updates
June 2019 ~
Aetna has released updates regarding how the insurer will handle certain Ambulatory Surgical Center (ASC) And Ambulatory Payment Classification (APC) code edits under the ASC and APC payment methodologies.
According to the insurer, specific CPT®/HCPCS codes that generate certain ASC and/or APC error codes that indicate a Medicare non-covered service or one that is not part of the Medicare ASC fee schedule or APC payment methodology will no longer be eligible for default payment.
Changes to an individual provider’s compensation will depend on the presence of the Medicare ASC and/or APC payment method within the provider contract. The changes are outlined below. NOTE: all updates will start on November 1, 2019, unless otherwise noted.
Description of ASC Edit |
Provider Types Affected |
What’s Changing |
| Not part of the ASC fee schedule (HCPCS codes not in Addendum AA, BB or EE) | Ambulatory surgery centers | Services will no longer be eligible for payment consistent with Medicare claims processing/payment rules. |
| HCPCS codes listed on Addendum EE The list includes services that are on the Outpatient Prospective Payment System (OPPS) inpatient list, unlisted CPT codes and surgical procedures that are not recognized for payment under Medicare. | Ambulatory surgery centers | Claims for covered services for members paid under the Medicare ASC payment method will be reimbursed at the outpatient contracted rate. |
| 9 | Noncovered under any Medicare outpatient benefit, for reasons other than statutory exclusion | Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate. |
| 10 | Service submitted for denial (condition code 21) | Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate. |
| 13 | Separate payment for services is not provided by Medicare | Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate. |
| 18 | Inpatient procedure | Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate. |
| 24 | Date out of OCE range | Service will no longer be eligible for payment consistent with Medicare processing rules. |
| 28 | Code not recognized by Medicare for outpatient claims; alternate code for same service may be available | Service will no longer be eligible for payment consistent with Medicare processing rules. |
| 50 | Noncovered under any Medicare outpatient benefit, based on statutory exclusion | Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate. |
| 59 | Clinical trial requires diagnosis code V707 as other than primary diagnosis (deleted, retroactive to the earliest included version) | Inactive code; no longer eligible for payment. |
| 61 | Service can only be billed to the DMERC | Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate. |
| 67 | Service provided prior to FDA approval | Service will no longer be eligible for payment consistent with Medicare processing rules. |
| 68 | Service provided prior to date of National Coverage Determination (NCD) approval | Based on coverage policy at the time of service; claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate. |
| 69 | Service provided outside approval period | Service will no longer be eligible for payment consistent with Medicare processing rules. |
| 80 | Mental health code not approved for partial hospitalization | Service will no longer be eligible for payment consistent with Medicare processing rules. |
| 81 | Mental health service not payable outside the partial hospitalization program | Service will no longer be eligible for payment consistent with Medicare processing rules. |
CPT® is a registered trademark of the American Medical Association.
Source(s): Aetna Office Link Updates; Aetna Current 90-day Notices and Material Changes;
