Dear Providers,
Claimpower identified an issue where Aetna is reimbursing CPT 99214 and 99215 at a down-coded rate. Under Aetna’s Claim and Code Review Program, these higher-level E/M services are downcoded due to their Evaluation and Management (E&M) Program.
What’s Happening?
Aetna partnered with a third-party vendor to review E&M coding. This vendor assesses whether Level 4 and 5 E&M codes accurately reflect service complexity and patient severity.
- Reviews are non-clinical and follow external coding guidelines.
- Certified coders analyze claim history and billing patterns to determine reimbursement levels.
- All CPT 99214 & 99215 claims now require medical records submission to the PCR department for review and processing.
If you receive a notification letter about this review, forward it to your Relationship Manager (RM).
Your RM will provide guidance on the next steps.
For questions or concerns, please reach out.