AOA/MOA Announce Aetna Modifier 25 Win
Jan 10th, 2020
In a significant win for DOs and their patients, Aetna has agreed to disable automatic claims denials of E/M services billed on the same day as OMT and appended with modifier 25. The AOA worked closely with our physician liaison at Aetna to implement the change, which allows E/M services billed on the same day as OMT codes 98925-98929 to bypass claims edits that previously triggered the denials. The Maine Osteopathic Association (MOA) also provided important advocacy support.
The change is effective for services rendered on or after January 1, 2020. For denials prior to this date, the AOA urges members to exercise the right to appeal unfavorable payer decisions. If Aetna rejects a claim for E/M services billed on the same day as OMT and appended with modifier 25 for services provided on or after January 1st, please contact AOA Physician Services for assistance.
For more information, visit the AOA’s Private Payer Advocacy page.
MOA Medical Economic Committee Advocating for Maine DOs
The Maine Osteopathic Association's Medical Economics Committee (formerly known as the MOA Payor/Payee Committee) has been actively engaged here on the local level with several payors on recent audits of claims relating to billing E/M and OMT codes on the same date of service with modifier 25. The Committee is co-chaired by Dr. Stephanie Collins and Dr. Kiran Mangalam with key input and advice from multiple committee members including Dr. Boyd Buser, former AOA and MOA President and national expert.
The Committee has held multiple conference calls with Anthem representatives in Maine to learn more about their policy on modifier 25 after a Provider Communications notice was sent out this spring. We have shared pertinent documents including the National Government Services (NGS) Local Coverage Determination for OMT; the CMS 2011 Federal Register; and the AMA RUC database pre-, intra-, and post- service work descriptions to demonstrate that the RUC and CMS took into account any potential overlap between the E/M and OMT codes when they established their values. Our discussions have been informative and we have an additional meeting scheduled for December. We anticipate that we will have information to share with the membership on or before the MOA Mid Winter Conference in February 2020.
In addition, the MOA Medical Economics Committee has met several times with Aetna to discuss the volume of DO practices impacted by their denials of E/M and OMT claims. We have shared the relevant documents and continue to have meaningful dialogue about osteopathic manipulative treatment.
We have also reached out to Martin's Point to discuss the recent audits that many DOs have been impacted by which include a look back of up to two years of claims submitted related to modifier 25 when an E/M is billed on the same date of service with an OMT code. While these conversations are in the beginning stages, we do encourage DOs to appeal and to keep a detailed paper trail. If you are in need of template letters to assist you with your appeal, please contact the MOA office at 207-623-1101.
The MOA continues to advocate for appropriate reimbursement. If you have questions or need information, please do not hesitate to reach out. Feel complete the MOA Hassle Factor Form and/or call the MOA office at 207-623-1101 to share your experience. This information helps us to track trends and changes in payment policy.
More on the topic from the AOA: 5 Ways to get more of your modifier 25 claims approved. Click HERE to read the full article.