I
finally finished editing my draft appeal (I'm going to delete the rough draft from my other post...), and I'm hoping I've succeeded in eviscerating Aetna and McKesson's claim-edit/coverage policy over this issue. It grew from a 2-page appeal with 6 pages of attachments, to 3 pages, with 10 attachments. The tone is pretty condescending, but I think that the absurdity of their rationale warrants it.
I've
never seen a payer policy that is
so incorrect, in
every possible way - literally every sentence was
completely false, or just irrelevant to the point they're trying to make. It looks like they just threw together a bunch of phrases that sounded good, without checking to see if any of it made sense, first, and made it an 'official policy' - It's almost laughable, really.
I'm determined to see this one through (and hoping this will be the only appeal I have to send) - McKesson provides scrubbing software for almost every major payer in the industry (if you've ever seen the words 'ClaimCheck" anywhere, that's who's behind it) - if they think that they can get away with just
making crap up and passing it off as legitimate, they'll only be encouraged to do it more often. This needs to be nipped in the bud. I'm sharing the final copy, for anyone else who comes across this - please feel free to use any of it in your own appeals over this issue, if you want...(I also attached a copy here, because I'm not going back through here and re-adding all of the bold and italics I used for emphasis - it was kind of a lot...
)
List of Attachments: (Copies of...)
1. Aetna's payment policy
2. McKesson's edit rationale
3. & 4. Printouts from the Medicare Physician Fee Schedule, showing 96372's 'Global' identifier as "XXX"
5. Printout from Highmark Medicare showing that a global designation of "XXX" = "Global concept does not apply"
6. & 7. Pages 514 & 515 of the 2011 CPT book, with 99051 circled, and the title of the Chapter at the top of the page (obnoxiously) circled/starred.
8. Page 4 of the CPT book, with the "Classification of E/M Services" guideline circled
9. Page 11 of the CPT book, with the title at the top circled/starred
10. Page 549 of the CPT book, with the definition of modifier 25 circled, and every single mention of "E/M Service", underlined.
(Sure, they
might have their own CPT book, but judging by their policy, I seriously doubt they know how to use it...)
"[Claim info redacted]
On the claim referenced above, we received a denial for CPT 99051, stating that it is incidental to another procedure performed on the same date. An Aetna provider services' representative advised our office that 99051 denied as, 'incidental to CPT 96372 from the same DOS', and referenced a reimbursement policy listed on Aetna's Secure Provider Website, Navinet, (https://www.aetna.com/contentMgt/pws/policies/afterhrs_weekend_cpt.html); and of which, I included a printout. (See: Attachment #1)
There are numerous, significant flaws with nearly every aspect of this policy, which Aetna has failed to address.
1. The denial is based on a custom edit, without any merit. This is not a CMS guideline. It is not an NCCI edit. In fact, CPT 99051 isn't listed anywhere on the NCCI edit tables, in conjunction with 96372 (or with any other service in the 90000-99999 code range, for that matter), either as being a component code, or a mutually-excluded service. An omission of the code pair in question, from the NCCI edit tables, should be taken as evidence, that CMS does not support Aetna's coding edit.
2. Just because a procedure is “minor�, does not mean that it has an inherent “emergency aspect�, to it. In this encounter, the patient received injectable drugs to treat acute sinusitis. Although the condition was acute, and was treated after regular business hours, nothing about the condition, or its treatment, qualified the services provided, as being rendered on an “emergency� basis. Getting a standard antibiotic shot does not constitute an emergency, under any reasonable interpretation, of the definition of the word, “emergency�. The given explanation is certainly not consistent with the published views of any objective, and reputable outside-sources (eg, CMS, AMA, any specialty societies, or academic institutions). McKesson's current claim edit rationale (as provided through Navinet – See “Attachment #2�), erroneously alludes to the CMS 'Global Days' policy, in support of the edit, but fails to take into account that:
A) CPT 96372 has a global period of "XXX", (i.e., the "Global concept does not apply" – See: Attachments #3, #4, and #5); Per CMS, “Codes with the global surgery indicator of “XXX� in the MFSDB can be paid separately without a modifier.�
(Source: Medicare Claims Processing Manual, pg. 104 http://www.cms.gov/manuals/downloads/clm104c12.pdf); and,
B) (Although it's a moot point in this case), merely having a global surgical period of any length, does not automatically deem a service 'emergent', under CMS's global surgical package concept, in the first place. There is no justification for denying 99051, based on the consideration of any characteristics, of 96372.
(See: pages 90-94 of the Medicare Claims Processing Manual, for more information on CMS's definition of the Global Surgical Package.)
3. It is absolutely NOT appropriate to append modifier 25 to 99051, under any circumstances, period. The mere coincidence of 99051 and E/M codes, both starting with "99", is not an affirmation that 99051 is an E/M code. Attachments #6 and #7 indicate the location of CPT 99051 in the AMA CPT 2011 book. Please note on attachment #7, that 99051 is not found in the Evaluation and Management portion of the book; it is found in the chapter for “Medicine/Special Services, Procedures, and Reports�. This was not an accident; it is not an E/M code – it's a special service, to be reported in addition to an E/M code.
Evaluation and Management codes indicate that a professional service was rendered to evaluate and/or treat a patient's condition (or to assess their health status, in the absence of any complaints), as described under the CPT Guidelines for Evaluation and Management Services, under the heading, “Classification of Evaluation and Management Services� (see: Attachment #8). 99051 in no way meets the definition of an E/M service; hence, the reason it is not classified as an E/M code, per CPT.
Attachment #9 is an example of CPT codes that are E/M services; please take note of the starred portion, where once again, CPT took care, to clearly label the name of the respective chapter, at the top of each page. Just as Attachments #6 and #7, indicate that services listed under that chapter are “Medicine/Special Services, Procedures, and Reports�, attachment #9 distinctly labels services listed in that particular section, “Evaluation and Management/Office or Other Outpatient Services�.
I reiterate the point, because the distinction between E/M, and non-E/M services, is an important one to make; it is crucial to the definition of Modifier 25. (See attachment #10). CPT indicates repeatedly, that modifier 25 is ONLY for use with E/M services. Therefore, it is not appropriate to append modifier 25 to non-E/M services (such as those found in the “Medicine/Special Services, Procedures, and Reports�, section), to indicate that the procedure/service in question was distinct, or separately identifiable from other procedures or services, performed on the same date.
CMS has taken the issue of provider-misuse of modifiers 25 and 59, extremely seriously, and has released several publications, regarding when it is appropriate to append those modifiers to services, and when it is not.
It is not appropriate, or necessary, to append either modifier to codes that, by definition:
• do not bundle to one another,
• are not components of one another,
• do not generally describe the same type of service; or,
• do not otherwise require some kind of supplemental designation, to identify them as being 'separate', from other services reported.
Simply adding a modifier to override a payer-edit, is explicitly prohibited. It is certainly not appropriate to use modifier 25 in the aforementioned manner, for non-E/M services.
Commercial payers have extraordinary flexibility in developing, and implementing their payment policies, which do not necessarily have to conform to CMS, or CPT guidelines; however, their coverage policies should be coherent, and should be supported by rationale that fundamentally meets some kind of nationally, or even regionally, accepted protocol. Policies should never require a provider to improperly code claims, in direct contrast to CPT and CMS guidelines; particularly under the guise of conforming to a non-existent, CMS rule.
Due to the fact that we have several patients who have Aetna, in addition to Medicare, and/or other primary/supplemental payers (whose policies and protocol are based on logical, and widely-accepted rationale); and, due to the fact that it would be unreasonable to employ special billing practices that are both unnecessary, and grossly incorrect; our providers cannot feasibly follow Aetna's given advice for billing 99051 in conjunction with 96372, in its current form.
Please reconsider your position on this issue; nothing about Aetna's policy supports its validity; it will not hold up to the even the lowest legally-recognized standards, upon appeal. Considering the volume of patients seen after hours, in many of our 50+ clinic locations, whose acute conditions may, occasionally, necessitate injection administrations; I can assure you that this will not be an isolated incident, and we will not relinquish a potentially-significant amount of revenue, on the whim of a baseless payer-policy, without exhausting every possible avenue of appeal, first.
Should your determination remain unfavorable, please expect that I will file a complaint with the Texas Department of Insurance, as well as any other entity who may be interested, in Aetna's promotion of blatantly aberrant coding practices, immediately upon receiving the Adverse Determination Notification. You may contact me at the number below with any questions.
Thank you,
Brandi Tadlock, CPC, CPC-P, CPMA
Coding and Compliance Analyst
[Redacted]"
