NCCI Edit Changes for Aetna, Cigna and Humana
Aetna, Cigna and Humana have all announced changes to their respective policies related to the National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits and the payment of a CPT code(s) that has had modifier 59 appended to it on the claim form. These positive changes would not have occurred without the advocacy of the American Physical Therapy Association (APTA).
Aetna
Aetna has informed
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Cigna
According to
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Humana
Humana has informed
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Hopefully Anthem follows suit
I agree!
Do you know exactly how we are supposed to resubmit the claims to Humana and when we can begin to resubmit them? I have a feeling that they may deny as duplicate and if we call, the phone reps will not understand. (Based on past experiences).
Also, does this just apply to eval code + 97140? Or will they reconsider 97140 with manual traction. Despite adding -59 modifier, we still receive denials at times.
I meant mechanical traction
You would want to look at the current version of NCCI edits to see what can and can’t be billed together and if allowed, is modifier 59 required.
Rick, can you answer the question from Debbie? “Do you know exactly how we are supposed to resubmit the claims to Humana and when we can begin to resubmit them? I have a feeling that they may deny as duplicate and if we call, the phone reps will not understand. (Based on past experiences).”
Humana has informed the APTA they will reprocess all claims that were denied based on the edits dating back to January 1, 2020 if a provider resubmits the claim. That is the answer we have at this time.
Hopefully Optum (Aetna) and American Specialty Health (Cigna) get the message also. I am not hopeful on that one.
Also, would be nice if Tricare also followed suit.
Has there been any update about the Speech 97130 code for these MA plans? Medicare allows up to 7 units for this code, however I noticed on 2021 claims, Humana is capping at 3!
This article only addresses NCCI edit updates and changes and not the amount of units an insurance carrier will reimburse per CPT code.
Hey Rick, this is Sandra in Heather’s office. So grateful to you
for keeping us informed, and APTA for their advocacy work. This is awesome news!
One question, does this mean that Aetna will no longer consider 97750 bundled.
You want to look at the current version of NCCI edits to see what is and is not considered bundled during that specific quarter.
Hi Rick, this is Fran from Physiofitness – I was wondering if there is any news about United Healthcare getting on board with accepting the NCCI edits like Aetna, Humana and Cigna. Could you comment on
this. Thanx as always for keeping us informed.
To my knowledge, UHC has been following the NCCI edits and we have not heard of any issues.
We just received an ERA back from Humana with a denial of 97535 using a modifier when we also had a 97530 billed. :/
You will need to contact Humana.
Have you heard anything on BCBS?
Not yet.
Just for clarification, do the NCCI edits apply to all plans (PPO/HMO) under these carriers or just the Medicare Advantage or Supplement plans?
It can be any of their plans.
Have there been updates on this? I still have not had Aetna reprocess any of these claims. When I recently contacted Aetna, the representative and the supervisor had no idea what I was talking about.
I am just now catching this. Is this only for services from 1/1/2020 – February 2021? Or is this still in effect? Do you have the reference to the announcement?
Still in effect and was announced by APTA.