Aetna Rolls Out Code Review Program

Beginning June 1, 2022, you may see new claim edits. According to Aetna, ”These are part of our Third-Party Claim and Code Review Program….support our continuing effort to process claims accurately for our commercial, Medicare and Student Health members. 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.

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.” Based on that statement, Aetna will not down code and pay you the lower fee, instead they will deny the claim all together. With this in mind, we recommend that you evaluate your documentation and billing for E/M services. Be sure it is in line with current coding guidelines. If you are not sure, refer to the KMC University Library resources titled Evaluation and Management (E/M) Documentation-An Overview. Additional information from Aetna can be found on page 3 of 46 in the March 2022 Aetna Links Update.