What Ophthalmology Practices Can Do

• Make sure your medical documentation clearly supports the level of E/M visit that is billed. Check out the American Academy of Ophthalmic Executives’ Medical Decision-Making Table: Office Based E/M for guidance.
• Verify the level of E/M submitted based on medical decision-making (MDM) was determined by meeting or exceeding two of three components (problems, data, and risk) at the same level of complexity.
• Confirm your claims are coded appropriately and that all diagnosis codes supported by the medical documentation are included.
• Monitor your remittances for downcoded claims and appeal when your documentation supports the higher-level code. We have seen Aetna use the remark code N22 (this procedure code was added/changed because it more accurately describes the services rendered) to denote downcoded claims.
• When ready, reach out to your Aetna network representative and request a “principal billing review.”

For more information on appealing downcoded claims and E/M coding resources including the MDM table, visit the Academy’s Practice Management section.

Next Steps

Although Aetna plans to continue the program, it committed to continuously evaluating and refining the claim edits based on feedback from the provider community. The Academy will continue to press Aetna on the administrative burden of appealing claims and share our members’ experiences with the program with the payer.