September 2018
Updates to Evaluation & Management (E&M) Code Billing

Dear Provider,
Aetna Better Health® of Ohio continues its commitment to correct coding and the implementation of programs that support nationally recognized and accepted coding policies and practices. Evaluation and Management (E&M) coding is an area that the Centers for Medicare & Medicaid Services (CMS) has identified as having significant error rates.
What does this change mean for my office?
Starting with claims for dates of service on or after January 1st 2019, we will evaluate the appropriateness of E&M coding reported using CMS and AMA documentation guidelines for Office Visit codes:
  • New Patients CPT codes 99201-99205,
  • Established Patients CPT codes 99211-99215, and
  • Office Consultations codes 99241-99245.
Based on the outcome of this evaluation, your payment may be adjusted if the information submitted on the claim does not support the level of service billed.

If your claim is adjusted for this reason, you will see the follow remittance information:
  • CARC 252 - an attachment / other documentation is required to adjudicate this claim / service
  • RARC M127 - missing patient medical record for this service
  • N183 - ALERT: - this is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits. 

Can I dispute a denial?
If you do not agree with a specific payment determination, you have the right to file a clinical editing dispute to this address:
Aetna Better Health of Ohio
Attn: Claims Department
PO Box 64205 Phoenix, AZ 85082-2198
As part of your dispute, you must submit the portion of the medical record that contains documentation to support the level of service you reported. We will review the submitted medical records to assess the intensity of service and complexity of medical decision-making for the E&M services reported. Aetna Better Health may adjust those claims where documentation substantiates the provision of a higher level of E&M service.
Aetna Better Health will evaluate this program periodically based on billing trends and may make adjustments as necessary.
Please direct any questions regarding this change to your Provider Relations rep or by calling Provider Services at 1-855-364-0974.

Provider Services
Aetna Better Health of Ohio