Wiki Aetna down coding

[Cheezum51]

Is anyone having trouble with Aetna automatically downcoding your E/M visit codes? I'm hearing that there have been so many complaints from OD offices about this that the AOA has lodged a formal complaint against Aetna.

If you've had this problem, have you found a solution to stopping it or are you having to appeal every claim?

Tom Cheezum, OD, CPC, COPC

 

[Annette123]

Yes Aetna is down coding the E/M visits. The only way to get them paid is to appeal each claim and it looks like this has been going on since August of Last year.

Annette Housel-Ghering, CPC

 

[Cheezum51]

I feel it's unethical, at best, and possibly illegal for them to arbitrarily decide to down code and then make offices go through appeals in order to be paid properly. I read in an article about this that if an office wins 50% or more of their appeals that Aetna will "remove the office from the program." Does that mean they'll stop down coding their claims automatically or does it mean they'll remove the office from the provider panel?

Billing and coding for payment for patient care has always been based upon a certain degree of trust between providers and insurers that providers will provide the necessary services and bill accordingly and thus expect payment without having to jump through arbitrary hoops. Unless Aetna has found through a significant number of coding audits that offices up code all the time, this is an issue which should be reported to state insurance commissioners and, if Medicare claims are also included, then to CMS as well.

Tom Cheezum, OD, CPC, COPC