Aetna recently expanded its claim and code review program, which results in the downcoding of certain level 4 and 5 evaluation and management (E/M) claims, similar to what Anthem has been doing for the last couple of years. In late March, the program was expanded from the initial 12 pilot states to all Aetna commercial states except Louisiana. Further expansion to Aetna Medicare Advantage plans is planned for later this year.

The program scrutinizes level 4 and 5 E/M claims for “correct coding” and performs prepayment edits as the payer deems appropriate. This results in certain claims being paid at a lower rate than originally billed. Because there will not be separate notifications when claims are downcoded, practices are advised to monitor remittance documents for appropriate reimbursement.

Inclusion in the program generally lasts for one year; however, practices can pursue early removal from the program by successfully appealing 75% of downcoded claims. Additional information about the program is available in Availity, Aetna’s provider portal.

To help avoid inclusion in the program and ensure appropriate reimbursement from Aetna and other payers, always verify benefits before each visit, as coverage and policies may change between visits. Additionally, providers need to code and bill the highest level of specificity for diagnoses and ensure proper documentation in the medical record. The overuse of unspecified ICD-10 codes and inadequate documentation can result in downcoding, which can impact reimbursement in rheumatology practices.

To help ensure proper claim processing, providers should:

• Use the most specific ICD-10 codes to support clinical findings. Unspecified codes should only be used if there is no other relevant diagnosis code available.
• Document clearly and thoroughly to support the level of service billed.
• Ensure medical necessity is met for the visit and supports the services rendered.
• Appeal downcoded claims when documentation supports a higher level of service.