Question AETNA CONSULTS

tscobee

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We are having trouble getting paid for initial date seen in the hospital by Aetna. They are saying the plan has a maximum number of services allowed for this procedure even though this is the first and only time our doctor has done a consult on this patient. I called Aetna and was told they pay the first provider that sends in their claim with this code no matter how many consulting doctors there are. I know they do not recognize consult codes 99243, 99244, and 99245 and the admitting doctor should add the AI modifier to the 99221, 99222, or 99223. How do all of the other consulting doctors get paid? Any ideas or suggestions on this. We are sending in a reconsideration with the hospital records, but I would hate to have to do this with every Aetna patient.
 

csperoni

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I'm not really up to date on the claim followup portion as that is handled by a centralized department at my organization. I have seen multiple postings about this issue with Aetna. I assume they may have recently changed their policy.
The CMS guideline is that multiple physicians may bill and be paid for 99221-99223 when consult codes were eliminated. Some private carriers follow that guideline. Others create their own. I do know there are some carriers who will only pay ONE physician for the initial codes 99221-99223 and expect all other physicians to bill subsequent 99231-99233 even if it is the first time that physician is evaluating the patient.
I would recommend asking Aetna for their policy. If you are participating, and this is an Aetna policy, then your best option for payment is 99231-99233.
 

CAROLYNB

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I am having the same difficulty with Anthem products stating only 1 initial visit code can be billed and normally that is the admitting physicians. My doctors are surgeons that are called in for evaluation, I have sent appeals to Anthem with no luck , do you have any suggestions?
 
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We are having trouble getting paid for initial date seen in the hospital by Aetna. They are saying the plan has a maximum number of services allowed for this procedure even though this is the first and only time our doctor has done a consult on this patient. I called Aetna and was told they pay the first provider that sends in their claim with this code no matter how many consulting doctors there are. I know they do not recognize consult codes 99243, 99244, and 99245 and the admitting doctor should add the AI modifier to the 99221, 99222, or 99223. How do all of the other consulting doctors get paid? Any ideas or suggestions on this. We are sending in a reconsideration with the hospital records, but I would hate to have to do this with every Aetna patient.
I've dealt with this a lot. In fact, Anthem is in the process of going back 3 years and recouping all payments made where we coded an initial inpatient visit instead of a subsequent. We're fighting them on this since they've supported the use of initial for any doctor seeing the patient for the first time up until now. Now they are only allowing the first claim submitted to use the initial code, no matter who submits. I found the same thing with the other major payors too. It seems Medicare may be the only one left allowing the use of initial codes by all doctors for the first visit. We have now decided to use the subsequent codes across the board to avoid issues because we found that even when we are the initial doctor seeing the patient or the admitting doctor, we may not be the first claim submitted, so ours gets denied. It's such a mess. The total so far for our Anthem recoupment is up to $27,000. They supposedly have a team working on this issue to allow us to resubmit corrected claims, but so far we're not seeing any progress on this and we've been working on this since June.
 
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