Aetna Articles and Resources

NEWS and Important Information

Reimbursement for code A9279 (monitoring feature/device)commercial and Medicare members. 01/01/2024
Effective January 1, 2024, Aetna® will no longer reimburse for code A9279, since it is considered statutorily non-covered. 

Healthcare Common Procedure Coding System (HCPCS) modifiers FX and FY 01/01/2024
This information applies to both our commercial and Medicare members. Effective January 1, 2024, we will reduce payment for radiology procedures billed with modifiers FX and FY to align with the Centers for Medicare & Medicaid Services (CMS) guidelines
•     Modifier FX (X-ray taken using film): A 20% payment reduction applies to the technical component (and the technical component of the global fee).

•     Modifier FY (computed radiography X-ray): A 10% payment reduction applies to the technical component (and the technical component of the global fee).

Aetna - Provider Resources: keep your information current as it could impact communications and claim payments.
Aetna - Claims, payment and reimbursement
Aetna - Provider Manuals
Aetna - Precertification List- Search by CPT Code to find out which codes require precertification
Aetna - Coordination of benefits (COB)
Aetna - Medical Clinical Policy Bulletins
Aetna - Legal notices,  updates, exchange Plans, underwriting disclosures

 

 

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May 6th, 2021

Identifying Risk-Adjusted Services During the Opioid Crisis

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Between June 2019 and June 2020, the United States saw a total of 107,750 deaths from COVID-19. The spread of this virus was so extraordinary that it led President Trump to declare a public health emergency, and we watched as individual states began implementing laws and regulations to limit social interaction ...
Apr 19th, 2021

Q/A: For E/M, How do I Count Tests Ordered in One Department and Performed in Another?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Question: I am in an ENT office as part of a large clinic with separate practices including audiology, CT, and allergy, all billing under the same TAX ID. Sometimes tests are ordered which are done in other departments that my office does not bill for, would those be considered an outside source? Answer: This is a great question and one that has been asked by many coders and auditors.
Mar 18th, 2021

How Reporting E/M Based on Time May Lose Money

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...
Apr 20th, 2020

Dismal OIG Report on Telemedicine

by  Wyn Staheli, Director of Content - innoviHealth

Providers need to understand the rules for reporting telemedicine services. A recent OIG report shows that this is not the case. What problems are being found in documentation claims? As providers are expanding their telehealth offerings, now is the time to understand the potential pitfalls since disallowed amounts will be taken back.
Apr 15th, 2020

New CPT® Codes Approved for COVID-19 Antibody Identification

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

On April 10, 2020, the American Medical Association approved and published a revision of code 86318 and added two new codes 86328 and 86769 for reporting Coronavirus [COVID-19] antibody testing.
Mar 24th, 2020

"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...
Mar 21st, 2020

Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)

by  Aubrie Rowley

The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...
Oct 1st, 2019

Do ICD-10 Updates Have Your Heart Beating Irregularly? Check Out the New Atrial Fibrillation Codes

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Atrial fibrillation (AF) is the most common type of abnormal heart rhythm (arrhythmia). It is caused by a disorder in the heart’s electrical system. AF is the result of abnormal contractions of the atria (upper two chambers of the heart) causing them to quiver and beat out of sync with ...
Jul 26th, 2019

Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage

by  NAMAS

Anthem has been very busy sending out notices stating that, beginning October 1, 2019, all timely filing deadlines for claims will be 90 days. We've seen this letter, or something very similar, sent to doctors and other healthcare providers from California to Kentucky. In their notice, Anthem states: "Effective for all commercial ...
Jun 13th, 2019

What Medical Necessity Tools Does Find-A-Code Offer?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...
May 29th, 2019

Noting "Noncontributory" for Past Medical, Family, Social History - Is It Acceptable?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?
Apr 23rd, 2019

Let's Talk High Risk E/M Services

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.   Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...
Apr 23rd, 2019

What is Medical Necessity and How Does Documentation Support It?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

We recently fielded the question, “What is medical necessity and how do I know if it's been met?" The AMA defines medical necessity as: It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
Mar 21st, 2019

The Impact of Medical Necessity on High Level E/M Services

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?"  The quick answer is, "it depends." Code 99233 has the following minimal component requirement: Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...
Mar 18th, 2019

How to Report Imaging (X-Rays) of the Thumb

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all ...
Mar 1st, 2019

Understanding NCCI Edits

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...
Jan 23rd, 2019

How to Report Co-Surgeons Using Modifier 62

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session. An easy way to explain this is to visualize a patient requiring cervical fusion where ...
Jan 4th, 2019

Nine New Codes for Fine Needle Aspirations (FNA) in 2019

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

If your practice performs a lot of fine needle aspirations (FNA), you probably have the code options memorized (10021 without image guidance and 10022 with image guidance). However, the 2019 CPT codes now include nine (9) new FNA codes (10004-10012), one deleted FNA code (10022) and one revised FNA code ...
Sep 14th, 2017

Double Dipping in the History of the Evaluation and Management Note

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them.  Double dipping occurs when the same information is used in more than one of the subcomponents of history. The subcomponents of history include: Chief Complaint ...
Feb 1st, 2016

Will Incident-To in Your Organization Pass a Compliance Audit?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Practices that bill incident to services need to periodically audit compliance with Medicare and private payor guidelines to avoid potential denials or third-party audits.

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Jun 17th, 2019

Telehealth Policies for Medicare and Commercial Payers 

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