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Friday, August 28, 2009

The health plan two-step

Most folks have heard of the Texas two-step. The Texas two-step is danced with two quick steps and two slow steps. 

The health plan two-step is even simpler. It is one step forward and one step backward. The latest demonstration comes courtesy of Aetna

In February 2006, Aetna agreed to pay the full allowed amount for a standard evaluation and management (E/M) service (e.g., a problem-oriented office visit), when billed with modifier 25 and a preventive E/M service. In essence, Aetna agreed to pay the full allowed amount for both services. This was progressive compared to other payers, like CIGNA and UnitedHealthcare, who only pay the acute service at a rate of 50 percent when done at the same encounter as a preventive medicine visit. Of course, some payers completely bundle the acute visit into the preventive visit in that scenario, resulting in payment only for the preventive service.

Anyway, Aetna took the second step of the health plan two-step earlier this month. Effective Aug. 15, 2009, Aetna began applying concurrency rules when two E/M services are billed and allowed with modifier 25, meaning each additional service is paid at less than the full amount. Aetna considers the preventive medicine visit to be the primary service and payable at 100 percent of the allowed amount; it considers the eligible office, or problem-focused, E/M to be the secondary service payable at 50 percent of the allowed amount. Apparently, there are others, like Aetna, who also giveth and taketh away.

The only upside that I can find in this particular dance is that Aetna's policy is now consistent with others' policies, so you have one less exception to remember. On the other hand, as Ralph Waldo Emerson once observed, "A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines." I guess Aetna thinks a lot of it, too.

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The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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