Wiki Aetna Medicare Denials LCD for office visit 99213

Create Wiki
S

Sammi

New
Messages
9
Location
Saint Simons, GA
Best answers
0
Has anyone had denials for LCD on a office visit for 99213 from Aetna Medicare? This just started Oct 1, 2022 so I'm assuming new fiscal years. Claims are being denied for LCD on an office visit with psychiatric DX codes, (these are not dementia or cognitive impairment codes). Medicare claims are clean and paying and I'm thinking there is a glitch in Aetna Medicare system. I have read the LCD L39266 which is what the Aetna Medicare representative instructed me to do but it does not pertain to general psychiatric codes. Any advisement?
 
I am working on several denials for this same reason. Came here for advise. The denial makes no sense and I had the representative send the claim back referencing a claim that was previously paid.
 
deautman said:
I am working on several denials for this same reason. Came here for advise. The denial makes no sense and I had the representative send the claim back referencing a claim that was previously paid.
Click to expand...
Yes, same here. The rep sent back for reprocessing and gave me the LCD L39266 reason for denial. Thank you so much for replying. This gives me hope there is a "glitch" in their system. If I find out anything further I will post. Thanks!
 
Sammi said:
Yes, same here. The rep sent back for reprocessing and gave me the LCD L39266 reason for denial. Thank you so much for replying. This gives me hope there is a "glitch" in their system. If I find out anything further I will post. Thanks!
Click to expand...
Also found this online...However when I look on Availity there is no information that would indicate that there should be a denial....

"Third-Party Claim and Code Review Program Beginning June 1, 2022, you may see new claim edits. These are part of our Third Party Claim and Code Review Program. These edits support our continuing effort to process claims accurately for our commercial, Medicare and Student Health members. You can view these edits on our Availity provider portal.* We are also expanding our claim edits for E&M services to our Medicare line of business with this update. This expansion enhances our prepayment claims editing processes for coding policy rules related to correct coding of E&M of levels of care for our Medicare members. We already apply these rules to our commercial line of business. These edits evaluate the correct coding for level 4 and 5 E&M codes (CPT codes 99204, 99205, 99214, 99215, 99244, 99245, 99204 and 92014) using the American Medical Association (AMA) E&M criteria. We will review claims billed with the following places of service: office, inpatient hospital, on campus — outpatient hospital, emergency room — hospital, off campus —outpatient hospital, and urgent care facility. Based on the outcome of the review, we may adjust your payment if the claim detail doesn’t support the billed level of service. We will not change the procedure code you bill. 4 These changes will support our goal of consistency across all lines of business. You can view any of these edits on our Availity® provider portal. For coding changes, go to: • Aetna Payer Space • Resources • Expanded Claim Edits Except for Student Health, you'll also have access to our code edit lookup tools. To find out if our new claim edits will apply to your claim, log in to our Availity provider portal. You'll need to know your Aetna® provider ID number (PIN) to access our code edit lookup tools. We may request medical records for certain claims, such as high-dollar claims, implant claims and bundled services claims, to help confirm coding accuracy. Note: This is subject to regulatory review and separate notification in Washington state"
 
deautman said:
Also found this online...However when I look on Availity there is no information that would indicate that there should be a denial....

"Third-Party Claim and Code Review Program Beginning June 1, 2022, you may see new claim edits. These are part of our Third Party Claim and Code Review Program. These edits support our continuing effort to process claims accurately for our commercial, Medicare and Student Health members. You can view these edits on our Availity provider portal.* We are also expanding our claim edits for E&M services to our Medicare line of business with this update. This expansion enhances our prepayment claims editing processes for coding policy rules related to correct coding of E&M of levels of care for our Medicare members. We already apply these rules to our commercial line of business. These edits evaluate the correct coding for level 4 and 5 E&M codes (CPT codes 99204, 99205, 99214, 99215, 99244, 99245, 99204 and 92014) using the American Medical Association (AMA) E&M criteria. We will review claims billed with the following places of service: office, inpatient hospital, on campus — outpatient hospital, emergency room — hospital, off campus —outpatient hospital, and urgent care facility. Based on the outcome of the review, we may adjust your payment if the claim detail doesn’t support the billed level of service. We will not change the procedure code you bill. 4 These changes will support our goal of consistency across all lines of business. You can view any of these edits on our Availity® provider portal. For coding changes, go to: • Aetna Payer Space • Resources • Expanded Claim Edits Except for Student Health, you'll also have access to our code edit lookup tools. To find out if our new claim edits will apply to your claim, log in to our Availity provider portal. You'll need to know your Aetna® provider ID number (PIN) to access our code edit lookup tools. We may request medical records for certain claims, such as high-dollar claims, implant claims and bundled services claims, to help confirm coding accuracy. Note: This is subject to regulatory review and separate notification in Washington state"
Click to expand...
Hmmm.. interesting and we were denied on some level 3 office visits as well, which should not be included in these edits according to the above rule. I'll look on availity as well and see if I can find anything. I didn't even think about looking on availity. Thank you!
 
lgardner said:
are you billing 99483 with the E/M?

this LCD is for Cognitive Assessment and Care Plan Service.
in the LCD Article: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=59036&ver=8
it mentions the CPT codes involved and includes 99202-99215 as services that cannot be reported together with 99483 on the same DOS.

not sure if this will help, but I thought I'd put it out there.
Click to expand...
Thanks for replying, No we do not use 99483. These are denying for just an office visit of 99213 or 99214.
 
I had 3 of these within 1 week - all coded for just an OV (99214 or 99204), all had Medicare Advantage plans, all were denied as "non-covered charges". I called and spoke with call reps and had all 3 sent back for reprocessing.
 
Hi, thank God! We are a dermatology office in NC, and we have been searching high and low for answers on THIS!!! ALL office visit codes are being denied, even office codes by themselves (meaning no procedure was done). I've had 15 claims with an office visit get denied by Aetna Medicare. We called and was told by the representative whenever you bill an office visit code we have to send records. We even caught a claim before sending it, printed off records, mailed the claim by paper with the records, tracked it, and they still denied it (using the LCD denial). THIS HAS TO BE A SYSTEM ISSUE. I faxed the Cognitive Assessment article to Aetna's medical records fax line asking them what this has to do with dermatology, and they sent me back an appeal form that I completed with my concerns as well as attached the Cognitive Assessment article with it(2 weeks ago). We are working with all NC dermatologist in our area on this issue and still have not had any success. We have googled and this is the first mention of this issue that we have seen since this has happen. Our timing shows this started after 10/13/2022 because claims with an office visit were being paid by Aetna Medicare before 10/13/2022. And all Aetna Medicare claims with an office visit code are still pending as well as the appeal form I faxed. Again, thank you!
 
lfontanez said:
I had 3 of these within 1 week - all coded for just an OV (99214 or 99204), all had Medicare Advantage plans, all were denied as "non-covered charges". I called and spoke with call reps and had all 3 sent back for reprocessing.
Click to expand...
Our Aetna Medicare denials said "non-covered charges" as well as the LCD denial. We called and was told by the rep each time we bill an OV code we have to send records. We caught a claim before sending it electronically and sent it by paper with the medical records and it still denied. It's like the reps are not on the same page!
 
Howard1Derm said:
Our Aetna Medicare denials said "non-covered charges" as well as the LCD denial. We called and was told by the rep each time we bill an OV code we have to send records. We caught a claim before sending it electronically and sent it by paper with the medical records and it still denied. It's like the reps are not on the same page!
Click to expand...
The 1st rep @ Aetna I spoke with immediately told me it was an LCD system glitch causing the errors. None of the reps I have spoken with have mentioned sending in records. We've had 1 claim reprocessed and paid but I am still waiting on the other 2 which one was a follow up visit (99214) and the other was a new patient OV (99204).
 
lfontanez said:
The 1st rep @ Aetna I spoke with immediately told me it was an LCD system glitch causing the errors. None of the reps I have spoken with have mentioned sending in records. We've had 1 claim reprocessed and paid but I am still waiting on the other 2 which one was a follow up visit (99214) and the other was a new patient OV (99204).
Click to expand...
So they are aware of the glitch but they are still sending me denials on the ov code. I just got 6 today. That means they're making me call and fix their mistake?! Not ok!
 
Howard1Derm said:
So they are aware of the glitch but they are still sending me denials on the ov code. I just got 6 today. That means they're making me call and fix their mistake?! Not ok!
Click to expand...
I 100% agree with you. The last person I had to call on - they sent me thru hoops to get to the "special team" that handled that plan...90 minutes later I finally spoke to an agent
 
Sammi said:
Just received a few more denials for the same LCD. I guess I’ll wait a few more days to see if this is corrected in their system. This is so frustrating but helpful to know other practices are having the same problem.
Click to expand...
Today I sent an appeal form with the EOB's that were denied attached, completed the appeal form with my concerns, and faxed it to their medical records fax line. This is an Aetna issue and I am not sitting on the phone for hours fixing their mistake. I spoke with a rep yesterday and asked her if Aetna had plans to go back into their system and reprocess all the claims denied in error, and her response was she did not know at this time and providers will have to call and they can send it back for reprocessing. Yeah, no!
 
Howard1Derm said:
Today I sent an appeal form with the EOB's that were denied attached, completed the appeal form with my concerns, and faxed it to their medical records fax line. This is an Aetna issue and I am not sitting on the phone for hours fixing their mistake. I spoke with a rep yesterday and asked her if Aetna had plans to go back into their system and reprocess all the claims denied in error, and her response was she did not know at this time and providers will have to call and they can send it back for reprocessing. Yeah, no!
Click to expand...
Exactly! I’m going to wait it out for another week and then go from there. I’m not thrilled with Aetna’s customer service. The usual response, they don’t know.. and generally they have no real answers. Sad.
 
Sammi said:
Exactly! I’m going to wait it out for another week and then go from there. I’m not thrilled with Aetna’s customer service. The usual response, they don’t know.. and generally they have no real answers. Sad.
Click to expand...
Thank you so much for bringing attention to this issue.
 
There is an issue in their systems so the claims with E/M are getting denied for LCD. They are working on it and all those affected claims will be reprocessed. :)
 
We are getting this same denial for our EM codes as well. I was unable to reach anyone at the provider line but when I sent an inquiry through availity they responded saying it was an LCD and sent me a link to an LCD that does not apply to what we are billing.
 
Sammi said:
Hmmm.. interesting and we were denied on some level 3 office visits as well, which should not be included in these edits according to the above rule. I'll look on availity as well and see if I can find anything. I didn't even think about looking on availity. Thank you!
Click to expand...
I actually used their code edit tool on availity and per their code edit tool the coding is correct.
 
You must log in or register to reply here.
Top