Aetna – You Can Now Send Electronic Claim Attachments!
Aetna is ready to receive your electronic claim attachments using the X12N 275 transaction. Right now, they are working with four vendors: Change Healthcare, Waystar, PNT Data, and SSI. If you submit claims through any of these vendors, contact them to see how to send us supporting documents online.
Not sure if your claims go through one of these vendors?
Ask your vendor if they use one of these companies. Even if your vendor is not ready yet, Aetna is working with other companies to implement the solution. Check out their vendor list and look for “Claim Attachments” in the “Transactions Available” column. Aetna will update the list every time a new vendor is ready.
What are the benefits?
Sending claim attachments electronically will significantly reduce the costs associated with paper-based attachments.
- Faster payment to providers
- More efficient processing of claims
- Ability to electronically track the additional information sent
- Protection for personal health information (PHI)
- Reduced costs for administrative work related to paper mail
- Save USPS and printing costs
If you are interested in getting prior authorizations notices online, reach out to your vendor. Aetna let you know when this other transaction becomes available.
Cigna Modifier 25 Policy Update
Effective May 25, 2023, Cigna will require the submission of office notes with claims submitted with E&M Codes 99212, 99213, 99214 and 99215 and modifier 25 when a minor procedure is billed.
The E&M line will be denied if we do not receive documentation that supports that a significant and separately identifiable service was performed.
The required office notes must be submitted via the dedicated fax number 833-462-1360 or to Modifer25MedicalRecords@Cigna.com. Claims should continue to be submitted electronically and must have the attachment indicator selected. Claims and documentation will also be accepted via mail.
- Include a cover sheet with the following information when submitting required office notes via fax or email: Provider or billing name
- Provider Tax ID Number (TIN)
- Alternate Member ID Number (AMI)
- Patient Name
- Date of service
Horizon BCBS of New Jersey Modifier 25 Policy
Horizon is changing how they consider and reimburse claims submitted for certain E&M codes appended with Modifier 25 and minor global surgical procedures for professional claims on the same date of service. Currently, when an E&M service appended with Modifier 25 is submitted for the same date of service as another procedure code (or codes) that represent services that have a global surgical period of 0, 10 or 90 days, their claim processing system considers the E&M service at 100 percent of the appropriate Horizon allowance.
What is Changing
Beginning on February 1, 2023, Horizon will change how they reimburse for non-preventive E&M services appended with Modifier 25 billed on the same date of service as procedure codes that have a global surgical period of 0 or 10 days for services rendered on February 1, 2023, and after. Horizon will reduce the reimbursement by 50% for the service with the lower relative value unit (RVU) or the provider’s submitted charges if less. They will no longer reimburse for the practice expense component twice (once in the E&M and once in the global day code). These changes are reflected in the Evaluation & Management Edits subsection of their ClaimsXten Editing Rules reimbursement policy. Procedures with a 90-day global surgical period will not be included as originally communicated.
The following E&M codes are included when appropriately appended with modifier 25:
- 99202 – 99205
- 99212 – 99215
- All E&M codes related to preventive and administration services
- Emergency Room E&M codes: 99281 – 99285
- Procedures having a 90-day global surgical period will not be included in this policy.
- Horizon fully insured commercial plans
- Braven Health℠ Medicare Advantage plans (participating providers only)
- Administrative Services Only group employer plans, including the New Jersey State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP)
- Federal Employee Plan
Are you using Modifier 25 Correctly?
Modifier 25 is always under scrutiny and lately we are seeing more insurance reimbursement policy updates regarding the usage of modifier 25, here are some helpful reminders for proper use.
Append modifier 25:
- only when a minor procedure or other service and a separate and significantE/M service were performed
- on the same patient
- by the same physician
- on the same date
Modifier 25 indicates that additional reimbursement is needed to account for the extra E/M work. The key is recognizing when the additional work is “significant” and, therefore, additionally billable.
What’s Significant and Separately Identifiable?
It is only appropriate to report the E/M with modifier 25 if, in addition to the procedure, the physician performs an E/M service that is beyond the usual pre-, intra-, and post-procedure associated care. This tells the payer that a new or existing problem was addressed at the time of another service/procedure and the patient’s condition required work above and beyond the other service provided or the usual care associated with the procedure performed.
Determine Appropriate Use
Typically, if the E/M service is unrelated to the minor procedure (i.e., for a different concern/complaint), the E/M may be reported separately. Additionally, if the E/M service occurs due to exacerbation of an existing condition or other change in the patient’s status, that service may be reported separately if it is independently supported by documentation. When deciding whether modifier 25 should be appended, ask yourself the following questions:
- Were the key components of a problem-oriented E/M service for the complaint or problem performed and documented?
- Could the complaint or problem stand alone as a billable service?
- Is there a different diagnosis for this portion of the visit?
- If the diagnosis is the same, did the physician perform extra work that went above and beyond the typical pre- or postoperative work associated with the procedure code?
Note, a different diagnosis code is not needed, and in some cases, the diagnosis code for the E/M code and the procedure code will be the same.
Justify Modifier 25
Clear, detailed physician documentation is key to demonstrating the thought process and supporting the medical decision making (MDM) involved during course of the treatment rendered. The available documentation should describe an independent, stand-alone E/M service in addition to the procedure. The E/M service must be significant, the documentation must substantiate this, and the physician work must be medically necessary.
Payment hinges on the provider appropriately and sufficiently documenting both the medically necessary E/M service and the procedure in the patient’s medical record to support the claim for these services.
Examples of the Appropriate use of Modifier 25
- An established patient was scheduled for a follow up E/M after a change in his blood pressure medications. The physician met the documentation requirements for a 99213. The patient then complained that he was washing dishes, dropped a glass and now his thigh muscle felt like a piece of glass went through his skin.
- Based on the signs and symptoms documented, the physician performed 20520 (removal of foreign body in muscle or tendon sheath; simple) which has 10 global days. The proper billing would be 99213 25 and 20520.
- An established patient sustained a severe laceration to the scalp. Before suturing the laceration, the physician performed and documented a comprehensive history and exam to determine if the patient sustained neurological damage. The physician then performed a 3.0 cm intermediate repair (12032) to the scalp.
- Based on the signs, symptoms, and conditions documented, the physician went above and beyond the normal preoperative work, it is appropriate to bill both the E/M and repair.
- A patient was scheduled to have a lesion removed from her right leg. The physician examined the lesion, infiltrated the lesion with 1% lidocaine. The lesion was removed, and a simple closure (11401) was performed.
- The sole purpose for the visit was for the lesion removal; therefore, billing an E/M with modifier 25 would not be appropriate.
- An established patient is seen in the office for debridement of mycotic nails. While examining the feet prior to the procedure, tinea pedis is noted. Use of previously prescribed topical cream to treat the tinea is recommended.
- In this case the tinea was noted incidentally in the course of the evaluation of the mycotic nails and does not constitute a significant and separately identifiable E/M service above and beyond the usual pre and post care associated with nail debridement.
Excellus BCBS News
In April, much of the content accessed on the provider portal will be moved to the secure area of the Excellus BCBS website, which will require login with a username and password to access the information.
Reminder that claim corrections can be submitted electronically by requesting a claim adjustment on the Excellus BCBS website, secure login is required. Do not follow the clinical editing dispute process unless you are disputing a denial without correcting any element of the claim.
Medicaid Renewals and Reviews
NYS Medicaid Managed Care, Child Health Plus and Essential Plan patient recertifications annual reviews are resuming. Patients may lose their coverage if they do not complete or are not familiar with the recertification process. Excellus BCBS is asking providers to share the following information with their patients regarding this process.
- Soon, NY State of Health will resume eligibility reviews and renewals for members enrolled in these programs.
- NY State of Health needs to be able to send you important information so you can complete your recertification.
- It is important to update your mailing address on file with NY State of Health or your county Medicaid office, using the best address where mail can always reach you.
- NY State of Health members can update your address online or by phone. It is easy, fast, and free!
- Online – Go to nystateofhealth.ny.gov and look for the option to update your address.
- By Phone – Call NY State of Health at 1-855-355-5777 (TTY: 1-800-662-1220) Monday – Friday, 8 am – 8 pm, or Saturday, 9 am – 1 pm
- If you have Medicaid through your county’s Medicaid office, contact your local office to update your address and contact information.
Documentation and Coding for Unconfirmed Conditions
According to ICD-10-CM Official Guidelines for Coding and Reporting, “Do not code diagnoses documented as probable, questionable, rule out or working diagnosis, or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”
Some guidelines to consider when coding signs and symptoms:
- Code for signs or symptoms in the absence of a definitive diagnosis
- Signs and symptoms should not be coded with a confirmed diagnosis if the symptom is integral to the diagnosis
- A symptom code is used with a confirmed diagnosis only when the symptom is not associated with the confirmed diagnosis
- Only code symptoms that are current/active
NYS Medicaid Announces Telemedicine Policy after the PHE Ends
To support the use of telehealth services, the NYS Medicaid program will continue to cover services delivered via audio-visual telehealth, when appropriate, if a member chooses to receive telehealth services in lieu of an in-person visit. Audio-visual visits must contain all elements of the billable procedure codes or rate codes and all required documentation.
Audio-only services will also continue to be covered when audio-visual services are not available or when the member chooses audio-only services in lieu of audio-visual telehealth or an in-person visit. Audio-only visits must contain all elements of the billable procedure codes and all required documentation. Providers must document in the chart why audio-only services were used for each audio-only encounter.
Click here here for further details on this policy.
United Healthcare Announces Additional Paperless Features
Beginning May 5, 2023, United Healthcare will no longer print and mail overpayment notification letters and appeal decision letters for their Community Plan lines of business. These letters can be viewed digitally either in the Document Library in the UHC Provider Portal or through the Application Programming Interface.
For additional information, click here.
United Healthcare will continue transitioning more features throughout 2023 and 2024.
Veteran’s Administration (VA) CHAMPVA Program to Eliminate Paper Check Payments
To align with the United States Treasury effort to eliminate paper check payments, per 31 C.F.R. Sec 208 – Management of Federal Agency Disbursements, that requires all Federal payments to be made via Electronic Funds Transfer (EFT), the VA is asking for assistance of CHAMPVA Providers to ensure that they have your EFT information on file before any future payments can be made to you. Click here to read a copy of the VA Letter regarding this transition.
EFT enrollment with the VA is a two-step process:
STEP 1: You must have an active ID.me account to access. Register for an account at https://www.id.me/. Once you submit your webform, you will receive a case number and an email confirmation.
STEP 2: Complete your easy EFT Enrollment today! Visit https://www.cep.fsc.va.gov/.
For additional questions, contact the VA FSC Customer Care Center by calling 512-460-5049 or emailing vafsccshd@va.gov. You may also contact the FSC Customer Care Center for a Direct Deposit/EFT Enrollment walkthrough User Guide.