And then there were three: Mega-insurer Humana has decided that it will follow suit with a recent Centers for Medicare & Medicaid Services decision and permit certain common current procedural terminology code pairings that were severely restricted by National Correct Coding Initiative Procedure to Procedure edits. The decision makes Humana the third major commercial payer to make the shift.
In response to advocacy efforts by APTA, CMS published new edit files effective Jan. 1, 2021, and made the edit deletions retroactively effective to Jan. 1, 2020. Humana’s policy is consistent with the CMS changes.
The Humana 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. The change is anticipated to have a positive impact on the provision of necessary care and reduce administrative burden associated with claim denials and appeals.
According to Humana, it will reprocess claims that were denied based on the edits dating back to Jan. 1, 2020, if a provider resubmits the claim.
The decision makes Humana the third major commercial insurer to drop the edits. In January, Cigna became the first major insurer to follow CMS' lead. Aetna followed in early February. Anthem has yet to release a final decision, but in preliminary communication with APTA, Anthem has indicated it will adopt the change as well. APTA is waiting on clarification on the time frame and whether 2020 claims will be reprocessed.
Each insurer is approaching the shift in slightly different ways when it comes to how claims will be processed:
- CIGNA will not retroactively process claims but will acknowledge the NCCI edits deletions starting Jan. 1, 2021.
- Aetna will retroactively reprocess claims to Jan 1, 2020. Providers do not need to resubmit their claims; instead, Aetna will auto-process the claims. The insurer says this could take several months.
- Humana will retroactively reprocess claims to Jan. 2, 2020; however, unlike Aetna, providers must resubmit claims.
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