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Aetna Clinical Payment, Coding and Policy Changes

Recent News


Procedure Effective Date Change
Laboratory and diagnostic interpretation Reminder Aetna allows payment for the diagnostic interpretation of one lab or diagnostic test performed per date of service across providers.  This policy has been in effect since 3/1/2007.
Precertification will not override incidental procedure denial 9/12/2011 Precertifications will not override related services that are considered incidental.  The effective date of this policy changed from 9/1/2011 to 9/12/2011.
Multiple procedure reductions for therapy procedures 11/14/2011 Effective for dates of service on or after 11/14/2011, multiple procedure reductions will be applied to certain therapy procedures.  The procedure with the highest practice expense RVU will be allowed at 100 percent.  The practice expense portion of each additional therapy service performed by the same provider group on the same date of service will be allowed at 80 percent.  The Therapies - Modalities per Date of Service payment policy still applies. 
Maternity coverage proration 12/1/2011

Aetna will only reimburse for services rendered while the patient is covered by Aetna.  Payment for global maternity care will be adjusted to account for the portion of prenatal care that would have been received prior to becoming covered by Aetna.  The patient's previous insurance carrier should be billed the balance. 
Radiation treatment management, 5 treatments 12/1/2011 77427 will be denied when billed with 77431, 77432 or 77435.  Modifier 59 will override this edit.
Per day limits 12/1/2011

Per day limits will apply to the following codes effective 12/1/2011:

2 Units per date of service for:
97804:  Medical nutrition therapy; group (2 or more individuals(s)), each 30 minutes

4 Units per date of service for:
86753: Antibody; protozoa, not elsewhere specified
96040:  Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family
97802 and 97803:  Medical nutrition therapy
E0956:  Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each

4 units per date of service (2 units per site, per side (LT, RT)) for:
L2755:  Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepeg composite, per segment
L5618-L5626:  Addition to lower extremity, test socket
L5673 and L5679:  Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for/for use with locking mechanism

5 units per date of service for:
88347:  Immunofluorescent study, each antibody; indirect method

8 units per date of service for:
50265:  Genetic counseling, under physician supervision, each 15 minutes

12 units per date of service for:
80101:  Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class

20 units per date of service for:
+97598:  Debridement, open wound, including topical applications(s), wound assessment, use of a whirlpool when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof
Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical, structure partial tolerance specifications - 77301 12/1/2011 77014, 77421, or 77435 will be denied when billed with code 77301.  Modifier 59 will override this edit.
Clinical pathology consultation - limited, without review of patient's history and medical records - 80500 12/1/2011 80500 will deny when billed with a code from range 80100-80299.  Modifier 59 will not override this edit.
Lyme disease and other tick-borne diseases - Clinical Policy Bulletin 0215 12/1/2011 78607 (brain imaging, tomographic (SPECT)) will be denied as Experimental and Investigational (E&I) when billed with diagnosis code 088.81 (Lyme Disease).