Tag: #aetna

Posted in #aetna, #Medicare, #Medicareadvantage, Training, Updates

Aetna and Mid Level Reimbursement EM Services update 2022

Posted on by KR2Medical Billing

According to Aetna June 2022 provider newsletter- Aetna will NO Longer pay for the mid level staff: nurse practitioners, physician assistants, certified nurse midwives and clinical nurse specialists, at 100%, if they are performing the following codes:

G0402-
Long description: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment
Short description: Initial preventive exam

G0438- Long description: Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

Short description: Ppps, initial visit

G0439- Long description: Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

Short description: Ppps, subseq visit

Note to Washington State providers: Your effective date for changes described in this article will be communicated following regulatory review.

How can you access the full policy?

Log in to Availity*** and follow these steps:

  1. Click on Payer Spaces > Aetna.
  2. In the search box, type “mid-level practitioners” and click Search.
  3. Choose “Mid-level Practitioners and Other Qualified Health Care Professionals — Resource.”

This policy applies to Aetna commercial and Medicare members.

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Posted in #aetna, #Medicare, #Medicareadvantage, Training, Updates

Aetna: Mid level practitioner reimbursement policy-07/01/2022

Posted on by KR2Medical Billing

This reimbursement policy update applies to AETNA Commercial Plans for Texas Medicare, Commercial and IVL exchange networks.

Recently, AETNA expanded their policy for midlevel reimbursement policy- that includes reimbursement at 75% of the negotiated fee or recognized charge for
covered services for the following mid level professionals:

audiologists, genetic counselors, massage therapists, nutritionists, respiratory therapists and registered dietitians

Effective 07/01/2022- AETNA will add reimbursement of 85% of physician market rate, unless otherwise contracted for (nurse practitioners, certified nurse midwives, physician assistants and clinical nurse specialists) regardless of contract, employment status or place of service (that is, office or facility).

Who and what is not affected?
• Mid-level providers with specific rates in their contract
• Certified registered nurse anesthetists and registered nurse first assistants
• Claims billed with an Assistant Surgery modifier
• Covered DME, orthotics, prosthetics, supplies, drugs, laboratory, radiology services
and immunizations billed by a mid-level practitioner
• Providers contracted through a third party or vendor

Does this change affect the precertification and concurrent management process?

No. Aetna® will continue to make utilization management decisions and send the
appropriate letters and other communications.

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Posted in Training, Updates

HEDIS Measure: Well-child visits in first 30 months.

Posted on by KR2Medical Billing

Bringing young children to see the primary care physician, for a well-care visit is extremely important.

These visits track:

Prevention: wellness visits ensure children receive scheduled immunizations that prevent illness. It is also a great opportunity to discuss nutrition and safety in the home.

Growth and development. Evaluating children for growth and development enables parents to see how much their children have grown since the last visit. It is also an opportunity to share the children’s development, to discuss milestones, social behaviors, and learning.

Raising concerns. Offering parents an opportunity to share concerns at the start of the visit will help in your evaluation of the patient. They may want to talk about development, sleep and eating habits and behaviors.

Team approach. Regular visits create strong, trustworthy relationships among physician, parent, and child. The American Academy of Pediatrics (AAP) supports well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental, and social health of a child.

Description of the measure:

Describes the percentage of members who had to the following number of well-child visits with a PCP during the last 15 months.

The rates are reported as follows:

Well-child visits in the first 15 months: Six or more well-child visits with children who turned age 15 months during the measurement year.

Well-child visits for ages 15 to 30 months: Two or more well-child visits with children who turned age 30 months during the measurement year.

In order to receive credit for this measure the following DX should be used:

  • ICD-10:110, Z00.111, Z00.121, Z00.129, Z00.2, Z00.3, Z02.5, Z76.1, Z76.2

The following CPT codes should be used:

  • CPT: 99381-99382, 99391-99392, 99461

The following HCPCS should be used:

  • HCPCS: G0438-G0439, S0302

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