Aetna NPL, Clinical Payment and Coding Policy Updates

September 2018 ~

Aetna has released its most recent updates to its National Precertification List (NPL), as well as several clinical payment and coding policy changes that are scheduled to take effect over the coming months. These updates are as follows.

Precertification Changes

Effective November 1, 2018, precertification is required for endoscopic nasal balloon dilation.

Effective January 1, 2019, precertification is required for the following:

  • Decompression surgery for Chiari malformation
  • Laminectomy with rhizotomy
  • Shoulder arthroplasty
  • Site of Care for Actemra IV® (tocilizumab), Entyvio® (vedolizumab), Orencia® (abatacept) and Simponi Aria® (golimumab)

Effective January 1, precertification will not be required for the following:

  • Actimmune® (interferon gamma-1b)
  • Gastrointestinal (GI) tract imaging through capsule endoscopy
  • Temodar® (temozolomide)
  • Xeloda® (capecitabine)
  • Zaltrap® (ziv-aflibercept)

Also as of January 1, Aetna will discontinue the pediatric congenital heart surgery steerage program. NOTE: All inpatient admissions will continue to require precertification.

Clinical Payment and Coding Policy Changes

The following clinical payment and coding policy changes will become effective on December 1, 2018:

Perfusionist Services – Aetna does not pay for perfusionist services when billed by an agency or individual. The perfusionist must look to the hospital for reimbursement when they provide services to a patient for inpatient or outpatient services. Aetna will pay the hospital for the technicians responsible for assembly and operation of pumps with an oxygenator or heat exchanger.

Expanded Claims Edits – Aetna announced in December 2017 and June 2018 that it expanded its claims editing capabilities by adding new third-party claims edits. Aetna is adding more edits effective December 1, 2018. To view these edits, check Aetna’s provider website for information. Providers will have access to a new prospective claims editing disclosure tool available on the provider website. After logging in, go to Plan Central > Aetna Claims Policy Information > Policy Information > Expanded Claims to find out if new claims edits will apply to a certain claim.

Syringe With Unlisted Dialysis Procedure – Aetna will no longer allow payment for Healthcare Common Procedure Coding System (HCPCS) code A4657 when billed with unlisted dialysis procedure code 90999.

Electrodes Frequency – Aetna will allow 48 units/pairs of HCPCS code A4556 per year.



Source(s): Aetna OfficeLink Updates September 2018;