Coding and Insurance Carrier Policy Updates from HIS

Medical Coding

HIS - Coding and Insurance Carrier Policy

At Healthcare Information Services, it is our goal to keep those in the healthcare industry informed about coding and insurance carrier policy updates that may impact their everyday operations. Staying informed about changes in coding is essential for healthcare practices so that submissions are accepted as consistently as possible and everyone at the practice is kept in the loop. We know that if you are working with an orthopedic or radiology practice, your focus is always on your patients, so we want to make the coding process easier by providing comprehensive revenue cycle management services and regular updates about the world of coding. Here, we’ll provide updates from specific insurance carriers, so keep reading to learn more.

Updates from Aetna

Coding updates from Aetna came at the end of July of this year. The carrier’s CPB, 2044, Wound Care was updated with information regarding treatments that are now considered medically necessary. EpiFix is now reviewed medically necessary for treatments under the following criteria. 

  • Treatment of partial and full-thickness neuropathic diabetic foot ulcers. In order to qualify, the ulcers must be present for longer than 6 weeks, with no capsule, tendon, or bone exposed. The treatment must be used in conjunction with standard diabetic ulcer care in order to qualify as medically necessary.
  • Treatment of difficult-to-heal chronic venous or diabetic partial and full-thickness ulcers of the lower extremity. Medical necessity is deemed if the ulcers have not responded to standard wound therapy after 4 weeks of treatment.

For all indications other than the ones listed above, Aetna considers EpiFix experimental and investigational.

Another treatment that underwent policy changes under Aetna is DermACELL. Changes for this treatment are similar to the ones for EpiFix – DermACELL is now considered medically necessary for treatment of partial and full-thickness neuropathic diabetic foot ulcers that have been present for at least 6 weeks and do not have a capsule, tendon, or bone exposed. Treatment used in conjunction with standard diabetic ulcer care is also required. 

Updates from Cigna

Cigna’s updates are more brief, and involve new acceptance standards and requirements for certain codes. Like Medicare and UnitedHealthcare, Cigna will soon be no longer accepting consultation codes 99241-99255. This change will go into effect on October 19, 2019. Cigna will also require precertification of spine fusion related CPT codes as of August 23rd. Being aware of these updates is the easiest way to ensure that submissions to Cigna are accepted without issue.

Updates from CMS

The release of CMS’ 2020 outpatient and ASC prospective payment system proposed rule at the end of July can potentially bring changes for ASCs and hospital outpatient departments. One of the proposals suggested by CMS is to add total knee arthroscopy, knee mosaicplasty, and three coronary intervention procedures to ASC’s list of covered procedures. They are looking for feedback on limitations that should be set for these procedures, which is due to CMS by the end of September. They also proposed making total hip arthroplasty eligible for Medicare reimbursement in hospital outpatient and inpatient settings by removing it from the inpatient only list. You can learn more about these and other updates proposed by CMS this summer here.

Boost the Efficiency of Your Practice with HIS

At Healthcare Information Services, your practice is our business. We offer comprehensive revenue cycle management services and practice management and consulting to orthopedic and radiology practices across the United States. When you outsource your RCM to us, we will handle each step of the process to ensure that your coding practices are optimized to their greatest capability. Our experts can bring your practice improved cash flow, maximized reimbursements, practice compliance, and increased efficiency and profitability. The expertise of our team of over 65 Certified Professional Coders will prove to you that your practice is better off with help from HIS. To learn more about recent insurance carrier and coding updates and for more information about all we have to offer, please contact us today.