Wiki Aetna Medicare Mid-Level E/M

[jennifer.r.wake]

Our office is having problems with Aenta Medicare (specifically Aetna Medicare Elite and Premier) denying our Physician Assistant E/M charges stating the provider type is ineligible to bill/perform the service (PI-170). They will pay other services on the claim, if any, (like a UA, EKG, etc) but will deny the E/M. When I talk to customer service, they say it doesn't seem right and send it back only to deny again. Then I am told there is a different HCPCs or CPT code we are supposed to use for PA's. Has anyone else encountered this? We are Out of Network with the Aetna Medicare plans, but until this year we have never had an issue billing under the PA and processing under Out of Network benefits. I can't seem to find any information on Aetna's website regarding their policy on this, either.

 

[SharonCollachi]

Some insurances are requiring modifier SA for services by a PA. The PA may not be allowed to bill on their own to that insurance, in which case the MD bills but with the SA modifier.

You have probably already found this Aetna Out of Network Guide.