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 centersServices 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 centersClaims for covered services for members paid under the Medicare ASC payment method will be reimbursed at the outpatient contracted rate.
9Noncovered under any Medicare outpatient benefit, for reasons other than statutory exclusionClaims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
10Service 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.
13Separate payment for services is not provided by MedicareClaims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
18Inpatient procedureClaims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
24Date out of OCE rangeService will no longer be eligible for payment consistent with Medicare processing rules.
28Code not recognized by Medicare for outpatient claims; alternate code for same service may be availableService will no longer be eligible for payment consistent with Medicare processing rules.
50Noncovered under any Medicare outpatient benefit, based on statutory exclusionClaims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
59Clinical trial requires diagnosis code V707 as other than primary diagnosis (deleted, retroactive to the earliest included version)Inactive code; no longer eligible for payment.
61Service can only be billed to the DMERCClaims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
67Service provided prior to FDA approvalService will no longer be eligible for payment consistent with Medicare processing rules.
68Service provided prior to date of National Coverage Determination (NCD) approvalBased 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.
69Service provided outside approval periodService will no longer be eligible for payment consistent with Medicare processing rules.
80Mental health code not approved for partial hospitalizationService will no longer be eligible for payment consistent with Medicare processing rules.
81Mental health service not payable outside the partial hospitalization programService 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;

 

 

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