Modifier -25
Aetna Coding Provisions-Background:
Aetna routinely disallows non-E&M services when billed
with an E&M service appended with modifier -25. Per the
Settlement, if a bill contains a CPT code for performance of an
evaluation and management CPT code appended with modifier -25 and a
CPT code for performance of non-evaluation and management service
procedure code, both codes shall be recognized and eligible for
payment, unless the clinical information indicates that the use of
the modifier -25 was inappropriate or Company has disclosed
pursuant to §7.8(c)(iii) that such services are not appropriately
reported together." Aetna has not disclosed that said
services are not appropriately reported together.
Additionally, if the same services are billed with a modifier -59
appended to the non E&M service the payor considers both codes
eligible. Modifier -25 and modifier -59 are appended to
services for the same reason; to identify distinct services
performed on the same day as other services. Modifier -25 is
appended to E&M services to designate the service as distinct
and separate. Modifier -59 is appended to non-E&M
services for the same reason.
Example #1 (Aetna):
Procedure code 99173 was billed with 99394-25. Payment for
procedure 99173 was denied. Per Section 7.8(c)(iii) of the
settlement "company shall publish on the Provider's website any
circumstances as to which it has determined that particular
services or procedures relative to the modifier -25 and -59, are
not appropriately reported together with those modifiers …" The
combination of 99173 and 99394-25 is not cited as appropriate to
report together. Aetna is not in compliance with Section
7.20(b)(iii); "if a bill contains a CPT code for performance of an
evaluation and management CPT code appended with a modifier -25 and
a CPT code for performance of a non-evaluation and management CPT
code appended with a modifier -25 and a CPT code for performance of
a non-evaluation and management service procedure code, both codes
shall be recognized and eligible for payment, unless the clinical
information indicates that use of the modifier -25 was
inappropriate or the Company has disclosed pursuant to 7.8(c(iii)
that services are not appropriately reported together." Per
CPT Guidelines (page 298, CPT 2004), regarding procedure coder
99173 "other identifiable services unrelated to this screening test
provided at the same time may be reported separately (e.g.,
preventative medicine services)." Please forward the
provider's full fee schedule allowance for procedure code 99173 as
relief.
Example #2 (Aetna):
Emergency Department Physicians treating Aetna Subscribers,
insureds, and Members presenting with signs or symptoms of acute
coronary conditions requiring an electrocardiogram, (a service
Aetna Policyholders believe to be a covered service) are routinely
denied reimbursement by Aetna. Aetna routinely denies the
code (CPT Code 93010; electrocardiogram with at least 12 leads,
interpretation and report only) when billed in conjunction with an
Evaluation and Management Code, (CPT codes
99281-99285). This is in violation of Section 7.20
(c)(iii) requiring recognition of both the E&M code and a
service procedure code, when appropriate clinical information is
provided. This code is routinely denied even when the E&M
code includes a -25 modifier indicating that the E&M service
and the 93010 procedure were separate and identifiable from one
another. This is systematically and routinely denied by
Aetna without review of the clinical information, indicating that
it is a systemic violation of Section 7 of the agreement under
Section 12.6(f) of the Settlement Agreement.
Attachments:
Copies of HCFA 1500 and electronic bills, EOBs
Timely Payment
Example #3 (CIGNA):
An OB/GYN practice was denied payment on claims due to the
patient's failure to select a primary care physician. This has
occurred even in the instance when a primary care physician is
indicated on the patient's insurance card. There was no
referral requirement, e.g. there has been no failure to obtain
required referrals or authorizations. This was a violation of
several provisions of the settlement agreement including Section
7.17 (Billing and Payment) and Section 7.23 (Efforts to Improve
Accuracy of Information about Eligibility of CIGNA HealthCare
Members).
Attachments:
Copies of HCFA 1500 and/or electronic bills, EOBs and CIGNA
Referral Policy.
Immunization
Example #4 (CIGNA):
The physician was a participating provider with CIGNA. CIGNA
HealthCare of North Carolina had established a fee schedule for the
licensed meningococcal vaccine (MCV4 or Menactra) at 50% of the
physician's billed charges. The vaccine has been recommended by the
Advisory Committee on Immunization Practices for certain high risk
groups, including adolescents and college freshman living in
dormitories. (Attached to dispute) This issue was of particular
concern in North Carolina; there have been several recent outbreaks
in North Carolina universities. Each outbreak brings in
numerous parents demanding vaccines for their children. (news
article attached)
CIGNA was paying for vaccine at the rate of 50% of billed
charges. The CIGNA Settlement Agreement says in Section
7.14(b):
Payment Rules for Injectibles, Durable Medical Equipment,
Administration of Vaccines, and Review of New Technologies:
CIGNA HealthCare agrees to pay a fee (per the applicable fee
schedule for a Participating Physician and a reasonable fee for
Non-Participating Physicians) for the administration of vaccines
and injectibles in addition to paying for such vaccines and
injectibles. CIGNA HealthCare agrees to pay Participating
Physicians for the cost of injectibles and vaccines at the rate
set forth in the applicable fee schedule in each market, as in
effect from time to time."
Thus, the agreement states that the
cost
of injectibles will be reimbursed. By setting individual rates at
50% of billed charges, CIGNA has made it virtually impossible for
physicians to recover the cost of vaccine, as required by the
agreement. For example, the cost of the vaccine is
approximately $84. In order to recover its costs, the
physician would be required to charge $168 per dose, prohibitively
expensive for most patients. Thus, if the physician's raise
their rates to cover costs, it will have the effect of denying the
vaccine to other private pay and uninsured patients. Sending
patients to the health department (as recommended by a CIGNA
provider relations representative) interfered with the
patient-to-physician relationship and interrupted continuity of
care. In any event, patients and employers have paid premiums
anticipating that medically necessary care will be reimbursed by
CIGNA rather than the taxpayer. Furthermore, a variable rate
set at 50% of each practice's billed charges does not constitute a
"fee schedule in each market" as contemplated by the agreement.
Because of the severity and urgency of the matter, we requested
an immediate change in its payment policy, and reimbursement of
physicians for the cost of their immunization vaccine as of the
effective date of the settlement agreement. In addition,
because of its urgent nature and its impact on patient care, an
expedited review was requested.
CIGNA changed their policy, made several months retroactively.
We are still contesting the date of payment retroactivity.
(CIGNA contends that the agreement does not in fact require that
they pay the cost of vaccine.)
Attachments:
Copies of HCFA 1500 and/or electronic bills, EOBs and CIGNA
Correspondence, Recommendations of Advisory Committee on
Immunization Practices and News Articles re: Meningitis Outbreak in
Local Colleges.
All Products
Example #5 (CIGNA):
An ophthalmologist was advised by CIGNA that in order to
participate in the PPO products, he must participate with the HMO
products. This product was handled through Opticare, a vision care
vendor. This is in violation of the "All Products" provisions
of the settlement agreement as follows:
7.13 Participating in CIGNA HealthCare's Network.
b. "All Products" or "All
Affiliates" Clauses.
CIGNA HealthCare
does not include provisions in its contracts with Class Members
that require, or purport to require, Class Members to participate
in one or more of CIGNA HealthCare's products (e.g., HMO, PPO,
POS, indemnity) as a condition of participating in any other
product, and shall not include such provisions in its contracts
with Class Members at least through the Termination Date. With
respect to CIGNA Behavioral Health, unless a psychiatrist,
psychiatric group practice or psychiatric facility and CIGNA
Behavioral Health, Inc. agree otherwise concerning Covered
Services to be provided by that psychiatrist or psychiatric
facility, psychiatrists who provide Covered Services to patients
for whom CIGNA Behavioral Health, Inc. provides managed
behavioral benefit and/or employee assistance program services
and network services (both CIGNA HealthCare patients and patients
covered under other health benefit arrangements) are
expected to provide such Covered Services to all such patients,
subject to Section 7.13.d.
CIGNA is in violation of this section through its requirement
that the physician contract with Opticare in order to retain his
participation in CIGNA HealthCare's network. Please note that
vision care programs are not mentioned in Section 7.13(b); CIGNA
Behavioral Health is the only exception to the all products
prohibition.
Attachments:
CIGNA Correspondence, Opticare Provider Directory.