• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below.
  • We're introducing new features and a new look to make the forums easier to use and more valuable to you. See what's new and let us know what you think!

Aetna E&M Policy

coop22

Networker
Messages
67
Best answers
0
Our office started to get denials for E&M stating this was partially or fully furnished by another provider. This is for a NEW PATIENT! 99204

Their new policy states FOR ALL PLANS "We allow 1 of this group of codes per patient per day across all providers based on CMS guidelines." CPT codes 99234-99236, 99238-99239 & 99221-99223.

We are starting to get multiple denials and 99204 was not even in their policy. Does anyone have the CMS guidelines for this because they are deff making this up!
 

Pathos

Expert
Messages
443
Location
Beaverton OR
Best answers
0
CMS says:

"New Patient: An individual who did not receive any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous 3 years. Established Patient: An individual who received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous 3 years. "

My local MAC (Noridian) helps by making this a little clearer (website with good examples too!):

"New Patient
Individual who has not received any professional services, Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty and subspecialty) within the previous 3 years.
For example, if a professional component of a previous procedure is billed in a 3-year time period, (e.g., lab interpretation) and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or electrocardiogram (EKG) etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.
If a patient was seen by a physician in a clinic and sometime during the 3-year period was seen again by that same physician at the same clinic, at another clinic, or in this physician's private practice, this is still an established patient situation. If this patient sees another physician of the same specialty and subspecialty at a location where the first physician also practices, this is also an established patient situation."


Now, I couldn't find Aetna's E/M policy, but I would be very surprised if they decided to deviate too much on that sense.

Possible reasons for the denial:

-The patient was seen by the same provider at a previous practice, within 3 years
-The patient was seen by a similar credentialed provider from the same practice (fairly common denial reason)

Remeber that all NPs are considered credentialed as Family Practice/Medicine and Nurse Practitioner (50), and are credentialed the same as other NPs regardless of their individual specialty (applies only to NPs though).

Without knowing additional details, it can be difficult to speculate other scenarios.

Hope this is helpful.

Additional readings:
 

coop22

Networker
Messages
67
Best answers
0
No we are a cardiac surgeons office. We are being denied off other offices under diff NPI's and Diff specialties. To us these are NEW patients.

Their new policy states FOR ALL PLANS "We allow 1 of this group of codes per patient per day across all providers based on CMS guidelines." CPT codes 99234-99236, 99238-99239 & 99221-99223.

Line above is taken from Aetna's policy. We only have one NP in our practice and we don't bill anything with her. Their denials are nonsense. And to say they go by CMS guidelines is not true!
 

coop22

Networker
Messages
67
Best answers
0
Message 005 "We were previously billed by and paid another provider for this service" D40
 

Pathos

Expert
Messages
443
Location
Beaverton OR
Best answers
0
Have you reached out to Aetna's provider relation reps? They should be able to explain their policy and why they are denying your 99204s. Health Plans often use edits when screening claims, and at times there are errors. This could be one of those times. However, make sure you have all your ducks in a row and can explain the New vs. Established rule to them.

Good luck!
 

coop22

Networker
Messages
67
Best answers
0
Yes we have and they state it is their policy no matter whom bills the code that they will only pay ONE per day! How are we supposed to know that and if our billing is behind theirs we lose the money! Its been happening for a couple months now. On ALL Aetna plans
 

coop22

Networker
Messages
67
Best answers
0
There is a long article in Provider Communications 2018

No Policy # But in Claim Payment and Coding Policies it's listed unter Evaluation and Management E&M Services Payment Policy
 
Messages
179
Best answers
0
Hi coop22
I bet the patient saw the same specialists, I would call Aetna and ask why was this claim denied, let them tell you why and then you can turn around and say, did the patient see the same type of specialists and see that they say
 

clarkmegan

Networker
Local Chapter Officer
Messages
48
Location
Newport News
Best answers
0
If your office is part of a larger network, then they will deny based on the same tax id regardless of different specialty.
 

coop22

Networker
Messages
67
Best answers
0
No we are a small office. Only 8 physicians on 1 tax ID. They are denying off physicians our office has nothing to do with. We are cardiac surgeons. The denials keep coming! It just started about 3 months ago.
 

Partha45

Networker
Messages
50
Location
Chennai Local Chapter
Best answers
0
We are faced the issue as long time, after verified with billing team, they said as both providers are different specialty but the claim was submitted in group NPI instead of Individual NPI#, Please check the same.

Because of your group contains with 8 providers may have billed any face to face service in another provider already so that claim getting denied.
 
Top