Aetna down coding (changing) submitted E&M codes

[dgdg]

We started receiving eobs this year from Aetna (not Part C) where we appropriately submit a 99214, but simply based on the diagnosis code(s), they change it to a 99213, and pay the corresponding rate.

Help!

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[chessknt]

We started receiving eobs this year from Aetna (not Part C) where we appropriately submit a 99214, but simply based on the diagnosis code(s), they change it to a 99213, and pay the corresponding rate.

Help!

Have your billers appeal every level 3 billed as a starting point and would have your practice manager reach out to them or draft a letter explaining that it is inappropriate and doesn't follow CMS guidelines.

 

[dgdg]

Thank you.

I certainly can research this, but what is the brief jist of the CMS guideline violated here?

 

[MMourousias]

Here is why they are down coding the services. I would recommend being more specific with diagnosis codes to avoid the edits. Procedure code 99214 is for 30-40 minutes of physician time so you need to make sure the most severe codes are documented. https://www.aetna.com/content/dam/a...s/documents-forms/ny-em-code-claim-review.pdf

 

[chessknt]

Here is why they are down coding the services. I would recommend being more specific with diagnosis codes to avoid the edits. Procedure code 99214 is for 30-40 minutes of physician time so you need to make sure the most severe codes are documented. https://www.aetna.com/content/dam/a...s/documents-forms/ny-em-code-claim-review.pdf

No it is for a level 4 visit which can be billed by time but ALSO by complexity--it has nothing to do with the number or severity of codes. For example I could code a 'cough', review/interpet a CT scan,m look at 3+ labs, and start a prescription medication for it and that is a level 4 visit right there.

 

[chessknt]

Thank you.

I certainly can research this, but what is the brief jist of the CMS guideline violated here?

I would argue that the coding guidelines from CMS do not specify certain codes that do not qualify as level 4 visits and that if they disagree with your coding notes they need to point out what elements it failed to reach in order to be paid at the level billed.

 

[MMourousias]

No it is for a level 4 visit which can be billed by time but ALSO by complexity--it has nothing to do with the number or severity of codes. For example I could code a 'cough', review/interpet a CT scan,m look at 3+ labs, and start a prescription medication for it and that is a level 4 visit right there.

When you are looking to bypass a software edit an insurance company implements it absolutely comes down to specificity and severity of diagnosis. Especially if you are only reporting one diagnosis. The claim edit software is not taking documentation into account when it is down coding the services. The goal should be to get paid on one claim submission and not to appeal dozens.

 

[chessknt]

When you are looking to bypass a software edit an insurance company implements it absolutely comes down to specificity and severity of diagnosis. Especially if you are only reporting one diagnosis. The claim edit software is not taking documentation into account when it is down coding the services. The goal should be to get paid on one claim submission and not to appeal dozens.

I agree in principle but this is a predatory and inappropriate practice that should be challenged. These parasites are leeching money out of the healthcare system they should at least be held accountable to the rules they helped invent. Hell if this is widespread enough we could create a class action though I have not personally seen this problem.

 

[HemeOncHopeful19]

When you are looking to bypass a software edit an insurance company implements it absolutely comes down to specificity and severity of diagnosis. Especially if you are only reporting one diagnosis. The claim edit software is not taking documentation into account when it is down coding the services. The goal should be to get paid on one claim submission and not to appeal dozens.

Editing a code without taking documentation into account does not sound like it should be legal...

 

[MMourousias]

Editing a code without taking documentation into account does not sound like it should be legal...

That is not what I proposed. The documentation always needs to support the service. My experience is that physicians will give a generic diagnosis such as diabetes as a diagnosis to be billed, but will not be specific as to if it is Type 1 or Type 2. They will not specify if there any complicating factors or additional issues such as neuropathy. Being as precise as possible with the diagnosis coding on the initial claim will bypass these edits.

 

[HemeOncHopeful19]

That is not what I proposed. The documentation always needs to support the service. My experience is that physicians will give a generic diagnosis such as diabetes as a diagnosis to be billed, but will not be specific as to if it is Type 1 or Type 2. They will not specify if there any complicating factors or additional issues such as neuropathy. Being as precise as possible with the diagnosis coding on the initial claim will bypass these edits.

Ok but if you bill as diabetes and your documentation shows that it is not controlled / at goal, you reviewed two labs and managed an Rx it shouldn’t matter whatsoever what diagnosis is billed… that is a 99214

 

[sloh]

Ok but if you bill as diabetes and your documentation shows that it is not controlled / at goal, you reviewed two labs and managed an Rx it shouldn’t matter whatsoever what diagnosis is billed… that is a 99214

I think he’s also saying that if you include a more specific/complex diagnosis/diagnoses while coding higher, it decreases your chances of getting audited at all bc you won’t get flagged. Of course, if you get audited and used a more simple diagnosis for a higher code, supporting documentation would vindicate you but it’s better to just avoid the headache in the first place

 

[tylerb1800]

u/sloh is right. There is a difference in dx code of E14 (diabetes unspecified) vs E11.22. Unspecified codes may be triggering some of the downcoding. I do not agree with it. Aetna is a pain.
We can always have another discussion about ICD codes but unfortunately it is what is used at the moment.

 

[chessknt]

I think he’s also saying that if you include a more specific/complex diagnosis/diagnoses while coding higher, it decreases your chances of getting audited at all bc you won’t get flagged. Of course, if you get audited and used a more simple diagnosis for a higher code, supporting documentation would vindicate you but it’s better to just avoid the headache in the first place

OP isn't being audited though, they are having a computer render a verdict in their favor automatically without any actual review which is wrong.

 

[sloh]

OP isn't being audited though, they are having a computer render a verdict in their favor automatically without any actual review which is wrong.

Yeah and I agree it isn’t fair at all, but this scenario is even worse than being audited bc it seems to be a reflexive downcoding based off icd-10 diagnoses. The OP isn’t even given a chance to defend their coding. Only way around it is to just play the game and pick more complex/specific diagnoses

 

[HemeOncHopeful19]

Yeah and I agree it isn’t fair at all, but this scenario is even worse than being audited bc it seems to be a reflexive downcoding based off icd-10 diagnoses. The OP isn’t even given a chance to defend their coding. Only way around it is to just play the game and pick more complex/specific diagnoses

Yeah THAT is what I am saying should not be legal… if this is truly as OP describes it sounds like they are downcoding based on ICD and not even reviewing documentation?

It wouldn’t shock me one bit tbh based on the peer to peers I usually have to do in Onc in which they deny imaging based on ICD without reading the note

 

[tylerb1800]

I can't imagine that this is illegal. I suspect if the OP looks at the contract that he signed with Aetna that they have language about downcoding or altering E/M codes. I believe Anthem does some of this as well.

 

[MMourousias]

It doesn't matter what is fair and what is not fair. Using claim editing software is completely legal. What matters is working with the system that is in place and not working against it. You can make the decision to have your internal biller waste their time appealing the claims or they can get it correct the first time. I can tell you as the owner of a revenue cycle management company that we would not routinely appeal these claims. We would advise the provider to be more specific and to include as many codes as possible to avoid the edits. Billing companies get paid to bill and not to appeal. Clearly there are times when claims need to be appealed, but avoiding a software edit is not one of them.

 

[chessknt]

It doesn't matter what is fair and what is not fair. Using claim editing software is completely legal. What matters is working with the system that is in place and not working against it. You can make the decision to have your internal biller waste their time appealing the claims or they can get it correct the first time. I can tell you as the owner of a revenue cycle management company that we would not routinely appeal these claims. We would advise the provider to be more specific and to include as many codes as possible to avoid the edits. Billing companies get paid to bill and not to appeal. Clearly there are times when claims need to be appealed, but avoiding a software edit is not one of them.

Oh look an administrative parasite sucking the life out of the system came to tell us that we need to do more work to get paid less and make sure it gets its piece for doing 'work' too. Thanks for that insightful comment, do I need to go bring the Aetna CEO some coffee too?

Also fun edit--not legal to downcode without review, multiple ongoing lawsuits with regards to this. I am sure one of the AI providers could mass automate appeals to take no time at all from a person and waste a ton of the insurance company's time to make this more punitive to them. If the ****ers want to downgrade the note they need to look at it and tell me why it is a lower level of service, not the other way around. I already wrote the goddamn thing, it is on them to read it if they think something is off.

 

[MMourousias]

Oh look an administrative parasite sucking the life out of the system came to tell us that we need to do more work to get paid less and make sure it gets its piece for doing 'work' too. Thanks for that insightful comment, do I need to go bring the Aetna CEO some coffee too?

Also fun edit--not legal to downcode without review, multiple ongoing lawsuits with regards to this. I am sure one of the AI providers could mass automate appeals to take no time at all from a person and waste a ton of the insurance company's time to make this more punitive to them. If the ****ers want to downgrade the note they need to look at it and tell me why it is a lower level of service, not the other way around. I already wrote the goddamn thing, it is on them to read it if they think something is off.

Is that what I said? I said that more accurate information needs to be provided on claims in order to get paid correctly. It wasn't your service that was being down coded it was for someone else. Hopefully my feedback helps that person get paid in the future.

 

[HemeOncHopeful19]

Is that what I said? I said that more accurate information needs to be provided on claims in order to get paid correctly. It wasn't your service that was being down coded it was for someone else. Hopefully my feedback helps that person get paid in the future.

Yeah we hear what you're saying but it really shouldn't work that way and you're kinda condescending about it.

Like if Aetna wants to downcode my note, they should have to actually read it and prove I overbilled, not the other way around.

 

[chessknt]

Yeah we hear what you're saying but it really shouldn't work that way and you're kinda condescending about it.

Like if Aetna wants to downcode my note, they should have to actually read it and prove I overbilled, not the other way around.

Automating the process is illegal for the sole purpose of downcoding outside of defined criteria (ie it is ok if mutually excluded codes are billed to automatically trash one of those but not to pick a less expensive code by default). The AMA won a lawsuit on this 20 years ago and more are ongoing.

It really should be fairly minimal effort to get an AI bot to automate appeals of every downcoded charge with the same level of effort they apparently gave it to create even more stupid. The same way they waste our time with peer to peer bull**** for medications they don't want to pay for because they aren't 'approved' for some ultra rare diagnosis because there are no ****ing medications approved for it....