In a significant victory for physicians, Aetna and representatives of various state medical societies have settled a dispute about the payment of certain so-called add-on codes, which are claims submitted for additional procedures by the same physician above and beyond the primary procedure. Aetna has agreed that it will retroactively pay claims with add-on codes for computer-aided digital (CAD) mammography and myocardial perfusion testing with dates of service on or after January 1, 2004.

The additional payments—both retroactive and ongoing—provide a substantial financial benefit for thousands of physicians nationwide.

When Aetna in May 2003 settled CMA’s RICO lawsuit, the health plan agreed to make numerous changes to its payment policies to make them more consistent with CPT coding guidelines. One such change was to pay all add-on codes from the date they became effective under CPT. The settlement language requires that “ ‘add-on’ codes, as designated by CPT, shall be recognized and eligible for payment as separate codes and shall not be subject to multiple procedure logic.”

Aetna did not, however, recognize codes for CAD mammography (CPT codes 76082 and 76083) and myocardial perfusion testing (CPT codes 78478 and 78480), and these claims were denied. Some physicians stopped filing claims for those services, after it became apparent that Aetna would not pay for them. A number of physicians filed RICO settlement compliance disputes regarding the denials of these codes and last year Aetna did begin paying for these add-on codes (effective April 1, 2005, for CAD mammography, and May 12, 2005, for myocardial perfusion testing).

CMA and representatives from other state medical societies continued to push Aetna to retroactively pay such claims. Thanks to tireless CMA advocacy, Aetna this week agreed to allow physicians to resubmit previously denied claims and to submit new claims with add-on codes for CAD mammography (with dates of service between January 1, 2004, and April 1, 2005) and myocardial perfusion testing (with dates of service between January 1, 2004, and May 12, 2005).

Physicians can begin submitting or resubmitting these on April 17. Instructions for resubmitting previously denied claims will soon be posted at Aetna’s provider website, http://www.aetna.com/provider. (Click on “Add-On Code Claims Payment,” which will be under “Features” in the lower right-hand corner.) New claims should be submitted following standard billing procedures. Both new and resubmitted claims must be filed no later than July 14. Practices may submit claims on behalf of physicians who worked for the practice when the service was provided, even if they are no longer employed there.

Physicians can call Aetna’s provider service center for more details (888/632-3862 for PPO plans or 800/624-0756 for HMO plans).

Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.