We always have an eye out for strategies that payers develop to avoid reimbursing providers for things they previously paid for routinely.

I know there is a lot going on these days. While we were preoccupied with our kids starting a new school year, the World Series, the fortunes of our favorite football teams, and of course, the election, Aetna published a new policy in the September 2016 edition of Aetna OfficeLink Updates.

In this newsletter, Aetna asserts its intent to downcode certain emergency department (ED) claims. Specifically, Aetna notes that CPT® code 99285 should be used in cases that are “of high severity, are potentially life-threatening, and require immediate attention of a physician.”

Aetna went on to state that when a hospital or a physician bills a Level 5 emergency room service with a designated minor diagnosis code, they will reduce the level 5 to a level 99284 (level 4 ED).

Although a comprehensive list of the designated minor diagnosis codes has not been made available, Aetna listed examples of constipation, earaches, and colds.

In the eyes of providers, the problem with this policy is the issue of differential diagnosis. When a patient comes to the ED, he or she is new to the ED physician treating them. And when considering the symptoms of a patient in the emergency room, there are conditions that may be minor but nonetheless similar to conditions that are truly life-threatening.

The Emergency Department Practice Management Association (EDPMA) wrote a letter commenting on the policy. The letter makes the point that the effort and resources that go in to treating a patient may not be reflected in the final diagnosis.

To justify use of CPT 99285, the physician must utilize highly complex medical decision-making and deal with symptoms that are severe and pose immediate threat to life or function.

This situation is often a grey area. Head injuries and pain, chest pain, and abdominal pain with clinical histories often can resolve themselves as non life-threatening conditions. Factors such as age, history, coexisting conditions, etc. can complicate the diagnostic process. The differential diagnosis for symptoms and conditions can be wide.  

The EDPMA notes that nothing in the AMA/CPT guidelines refers to the final diagnosis as a factor to be considered in the assignment of the ED evaluation and management (E&M) code.

The final diagnosis truly does not always reflect the resources consumed and the risk associated with individual patients.

There is precedence that the use of the final diagnosis is considered an abuse by payers.

The EDPMA has called for this policy to be rescinded.

If it is not, EDPMA will call for Aetna to send notice of its intent to stick with this policy and to publish its list of “designated minor diagnosis codes” so that providers can judge more accurately how this policy will affect them.

Keep an eye on the Aetna website and any communications from Aetna to track the progress of this issue.

Share This Article