Question AETNA DENIALS MAINLY WITH W BEGINNING OF ID#

codeds07

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Hello All,
We are getting denials for the codes 99203-99205 outpatient office/hosp. and 99221-99223 inpatient, Aetna is stating they only pay 1 provider of this group of codes per patient per day across all providers. The EOB message 005 states " we were previously billed by and paid another provider for svc". The question is: Has any other practice had this issue??? and if so, how was it resolved?? I tried reaching out to talk to a provider liaison and they don't get back to me. How can they just pay one physician especially hospital patients that see a multitude of doctors while in hosp.? Any guidance would will be appreciated

Thank you,
Donna S.
 
Regarding 99221-99223 for initial inpatient, while CMS guidelines will permit multiple physicians to bill the "initial" codes, some commercial carriers may only pay one clinician for the "initial" (should be the admitting but in reality is whoever submits first), and any other providers must bill 99231-99233 for subsequent. Almost all my contracts specify CMS guidelines when there are differing guidelines. You should check your contract or see if Aetna has a policy on this.

For 99202-99205, it is certainly feasible and reasonable for a patient to see a new gastroenterologist in the morning, and a new cardiologist later that same day. Neither would have access to the other's records to even be aware this is occurring. If Aetna has a policy prohibiting this, that is absurd, but I have seen some crazy insurance policies.

I suggest checking the Aetna website. You could try asking a customer service rep what specific policy name/number it is to help you locate it.
 
Regarding 99221-99223 for initial inpatient, while CMS guidelines will permit multiple physicians to bill the "initial" codes, some commercial carriers may only pay one clinician for the "initial" (should be the admitting but in reality is whoever submits first), and any other providers must bill 99231-99233 for subsequent. Almost all my contracts specify CMS guidelines when there are differing guidelines. You should check your contract or see if Aetna has a policy on this.

For 99202-99205, it is certainly feasible and reasonable for a patient to see a new gastroenterologist in the morning, and a new cardiologist later that same day. Neither would have access to the other's records to even be aware this is occurring. If Aetna has a policy prohibiting this, that is absurd, but I have seen some crazy insurance policies.

I suggest checking the Aetna website. You could try asking a customer service rep what specific policy name/number it is to help you locate it.
Thank you csperoni for your information! appreciate it
 
My guess is that they still use Consultation codes 99241-99245 99251-99255. There aren't many payers out there that do, but the fact that they are saying they only allow one "initial" visit per day leads me to believe that they want Consult codes from consulting physicians.

It is always best to reach out to the carrier to confirm, of course.

*edited to correct typo
 
I've had the same problem with Aetna Medicare plans, they follow medicare guidelines which states we cannot use consultation codes and must use codes for inpatient initial visit, however deny my claims. I've gone to appeals and still have an issue.
 
Do you have Nurse Practitioners and Physician Assistants in your Group?

I ask because we have recently started seeing claims performed by physicians of different Specialties in our group being denied to each other.

It turns out that one of the Specialist claims was performed by an APP -- the carrier does not recognize NPs or PAs as a separate specialty. Since they bill under the same TIN as the physicians, the carriers are denying all E&Ms under that TIN that are performed on the same day as inclusive to the NP or PA claim no matter what the physician's specialty is.

So if the Surgical Consult is done by an APP, we'll get denials for the Cardiologist's consult, the Pulmonolgist's consult, etc. even though these physicians are different specialties from that Surgeon; but becaue their APP did the consult, the carrier does not recognize that the APP was working for Surgery - they just see that the APP has the same TIN as the other Specialists and they deny the rest. We're still trying to get these straightened out :(
 
I've had the same problem with Aetna Medicare plans, they follow medicare guidelines which states we cannot use consultation codes and must use codes for inpatient initial visit, however deny my claims. I've gone to appeals and still have an issue.
Hi Ccallycat, we havent had the issue with medicare they seem to be just the hmo claims, it seems since they see that primary doctor and thats all they pay, I have read in the provider manual for Aetna that we should be billing subsequent codes? weird but we should be getting something. I am also trying to request a physician fee schedule from Aetna see if I can see any codes that would be helpful, it's so hard I can't find a monmouth cty nj rep for aetna to get back to me or any other info regarding, hate this insurance!
 
Do you have Nurse Practitioners and Physician Assistants in your Group?

I ask because we have recently started seeing claims performed by physicians of different Specialties in our group being denied to each other.

It turns out that one of the Specialist claims was performed by an APP -- the carrier does not recognize NPs or PAs as a separate specialty. Since they bill under the same TIN as the physicians, the carriers are denying all E&Ms under that TIN that are performed on the same day as inclusive to the NP or PA claim no matter what the physician's specialty is.

So if the Surgical Consult is done by an APP, we'll get denials for the Cardiologist's consult, the Pulmonolgist's consult, etc. even though these physicians are different specialties from that Surgeon; but becaue their APP did the consult, the carrier does not recognize that the APP was working for Surgery - they just see that the APP has the same TIN as the other Specialists and they deny the rest. We're still trying to get these straightened out :(
HI Carol, yes we do have a NP, since she sees patients as f/u only in hospital I have appended Modifer SA? and they have been paying on that modifier. Havent seen any issues yet, I deal mainly with all hospital issues, I am not sure what the office does when the NP sees patients there...sorry....it gets so frustrating sometimes doesn't it :(
 
Hi Ccallycat, we havent had the issue with medicare they seem to be just the hmo claims, it seems since they see that primary doctor and thats all they pay, I have read in the provider manual for Aetna that we should be billing subsequent codes? weird but we should be getting something. I am also trying to request a physician fee schedule from Aetna see if I can see any codes that would be helpful, it's so hard I can't find a monmouth cty nj rep for aetna to get back to me or any other info regarding, hate this insurance!
Yeah I saw someone else saying they bill subsequent codes if initial gets denied, I just cant justify doing that when we've never seen patient! I think its the Medicare HMO the ones that start with MEB, I haven't had it a lot but boy they fight me on it tooth and nail, and I'm always apologizing to rep saying I know you're not the one denying it but come on! does it make sense?? LOL I know I keep saying I hate insurance companies, yet here I am dealing with them every day!!
 
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