Aetna recently announced that it would stop bundling evaluation and management (E&M) codes submitted on the same date of service in two circumstances. Aetna will now pay physicians for problem-oriented evaluation and management (E&M) services provided during a preventive services visit, when billed with modifier 25. Aetna will also reimburse physicians for E&M services when billed with modifier 57, performed on the same day as a decision for major surgery (global, 90-day procedure). These changes are consistent with CPT coding guidelines.

Although these policy changes were announced last year, their implementation was delayed and Aetna’s claims processing systems finally began recognizing E&M Codes with these modifiers effective February 11. Physicians can, however, resubmit previously denied claims for these codes with dates of service on or after August 15, 2005.

The changes were recommended by Aetna’s Physicians Advisory Board, which was created as part of Aetna’s RICO lawsuit settlement. Aetna in 2003 became the first HMO to settle with CMA and more than a dozen other state medical associations in CMA’s RICO lawsuit. Since then, six other HMOs have settled the fraud and racketeering cases. CMA filed the lawsuit six years ago, challenging the rapacious tactics of the for-profit managed care industry. The case allowed physicians to air profound grievances against an industry that has unfairly exploited them for more than a decade.

Modifier 25: This modifier is used when there was a significant, separately identifiable E&M service provided by the same physician on the same day as another procedure or service. For example, you see an Aetna patient for her annual well-woman check-up and during the visit she mentions that she’s been having significant neck pain. You can bill for the well-woman exam and for your E&M services related to the neck pain, with a modifier 25 attached to the latter code. The codes affected by this policy change are 99381-99387, 99391-99397, 99201-99205, and 99211-99215.

Note: Some pending Aetna settlement compliance disputes will likely result in additional payments to physicians for modifier-25-related reasons beyond those described above. The settlement language requires that “if a bill contains a CPT code for performance of an evaluation and management code appended with a modifier 25 and a CPT code for performance of a nonevaluation and management service procedure code, both codes shall be recognized and eligible for payment.”

Modifier 57: This modifier is used on E&M services that resulted in a decision to perform major surgery. For example, an Aetna patient comes in complaining of neck pain. You examine the patient, diagnose a fractured clavicle, and decide that surgery is indicated to treat the closed fracture. You can bill for the examination (with modifier 57) and for the decision for surgery.

Note: Some Aetna settlement compliance disputes are pending that may result in additional payments for modifier 57 claims with dates of service prior to August 15, 2005. The settlement language requires that “no global periods for surgical procedures shall be longer than any period than designated on a national basis by [the Centers for Medicare & Medicaid Services] for such surgical procedures.” CMA believes that this provision entitles physicians to reimbursement for modifier 57 claims that are consistent with Medicare payment rules with dates of service on or after May 21, 2003 (the date the Aetna settlement became final).

Stay tuned to future issues of CMA Alert for more information on RICO settlement enforcement activities.

Contact: Frank Navarro, 916/444-5532 or fnavarro@cmanet.org.