Aetna draws criticism for automatic down-codes for office visits

Providers are concerned a new national policy from Aetna involving evaluation and management services will result in inappropriate down-codes.

Under the policy, Aetna will automatically down-code claims submitted for office visits or certain modifiers when the the insurer finds an "apparent overcode rate of 50 percent or higher." The policy concerns office visits with the 99000 series of evaluation and management codes and the 92000 series of ophthalmologic examination codes, as well as modifiers 25 and 59, the American Optometric Association said in an advocacy post.

AOA said Aetna didn't explain how an overcoding determination is made under the insurer's algorithm, whether with or without medical record reviews.

"The AOA believes it is inappropriate to downcode such claims without first reviewing actual medical records and questions whether it complies with HIPAA; a variety of state laws related to fair, accurate and timely processing of claims; and Aetna's contracts with patients and physicians alike," the association said on its advocacy page.

Physicians can appeal down-coded claims through Aetna's internal process.

In a statement to Becker's Hospital Review, Aetna explained why it implemented the policy:

"We periodically review our claims data for correct coding and to implement programs that support nationally recognized and accepted coding policies and practices. Through a recent review, we identified healthcare providers across several specialties who are significant outliers with respect to coding practices. While we recognize that healthcare providers undoubtedly may have complex medical cases that are unique to their practice, this result is much higher than the average for physicians across most specialties.

"For this small, targeted group of healthcare providers, we will review their claims against [American Medical Association] and CMS coding guidelines. Based on that review, we may potentially adjust their payments if the information on the claim is not supported by the level of service documented in the medical record."

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