In a major payment shift, mega-insurer Aetna has decided to follow suit with a recent U.S. Centers for Medicare & Medicaid decision and permit certain common current procedural terminology code pairings that were severely restricted by National Correct Coding Initiative Procedure to Procedure edits. APTA is pressing for other commercial insurers to make similar changes.
In response to advocacy efforts by APTA, CMS published new edits files effective Jan. 1, 2021, and made the edit deletions retroactively effective to Jan. 1, 2020. Aetna’s policy is consistent with the CMS changes.
The Aetna decision significantly reduces the instances in which a PT will need to append the 59, X, XE, XP, XS, or XU modifiers and will eliminate situations in which certain code pairs were prohibited. This will have a positive impact on the provision of necessary care and a reduction in administrative burden associated with claim denials and appeals.
According to Aetna, it will reprocess all claims that were denied based on the edits dating back to Jan. 1, 2020. Providers do not need to resubmit these claims; however, Aetna said it will take several months to reprocess them.
Last month, Cigna became the first major insurer to follow CMS' lead. Aetna is now the second. APTA is continuing to advocate that Humana and Anthem to do the same.