Aetna and Humana collaborate with AOA to exempt optometrists from auto- downcoding edits

AOA advocacy has resulted in a first-of-its-kind organizational agreement to eliminate certain automatic downcoding programs, which have been targeting optometry practices across the country. In addition, the highly productive dialog involving the AOA and insurance giants Aetna and Humana that has been focused on optometry’s essential and expanding role in health care are continuing in an effort to build on these important medical insurance claim processing changes.  

“In health care, partnerships are highly essential to solving urgent patient access, coverage and reimbursement issues, and that is the case here,” says Steven T. Reed, O.D., AOA advocacy chair and immediate past president. “Today’s favorable claim processing changes are the direct result of our joint efforts with Aetna and Humana to address concerns and progress toward a fair and mutually respected medical eye care claim processing and reimbursement system.” 

Across the health care sector, physician complaints about downcoding—a payer practice of assigning a lower-cost medical service code than what was actually provided without record review—have been on the rise. Until now, downcoding complaints have been typically addressed through individual escalation efforts, including those backed by the AOA and state affiliates, through internal appeals processes and by alerting state insurance departments. 

Specifically, on Aug. 24, Humana removed doctors of optometry from its “auto-downcoding” program for 99xxx codes (evaluation and management codes). No auto-downcoding program exists for CPT 92xxx codes for Humana. 

As of Sept. 28, Aetna will no longer apply “auto-downcoding” to 92xxx codes for any doctor of optometry but may select “billing outliers” to retain the 99xxx downcoding program that applies to all physicians. Doctors who have claims that were auto-downcoded prior to those dates should appeal against those denials. 

The AOA’s resources for appeals are available here. 

In addition, Cigna has announced a new downcoding program that went into effect on Oct. 1, for level 4 and level 5 evaluation and management codes. Cigna has indicated that certain conditions were targeted, such as sore throat and earache, to identify doctors routinely billing higher-level evaluation and management codes. The AOA met with Cigna leaders to discuss the program and, based on the criteria of the program shared, it is anticipated that few doctors of optometry will be included in the Cigna downcoding program. Doctors who have claims downcoded by Cigna should appeal and also report to stopplanabuses@aoa.org immediately. 

Pushback continues against ongoing downcoding practices 

The AOA continues to oppose the use of any automatic downcoding systems, such as Aetna’s 99xxx downcoding program. “AOA has been working closely with Aetna for more than a year,” says Rebecca Wartman, O.D., chair of the AOA Coding & Reimbursement Committee. “We have been able to get Aetna to stop auto-downcoding the general ophthalmologic codes. However, we need more progress in getting optometrists completely removed from the auto-downcoding for the Evaluation and Management codes.”   

Doctors of optometry who are impacted by any downcoding should appeal every claim, Dr. Wartman says, and report the downcoding to stopplanabuses@aoa.org. AOA’s Third-Party Center (TPC) can help you craft an appeal and will provide updated and ongoing guidance. 

“With AOA assistance, the AOA TPC has been successful in getting optometrists removed from the Aetna plan on the second level of appeal,” Dr. Wartman says. “Providers should ensure that all medical records submitted for any appeal process are legible and complete and are not abbreviated in any manner.” 

Appropriate and complete and comprehensive documentation is the best defense against any downcoding or post payment review audit.  

Health plans are obligated to review and scrutinize claims and documentation to ensure appropriate payment under program payment integrity guidelines. Clinical documentation is the most important safeguard to being paid appropriately and keeping the money paid should retrospective audits occur in the future. 

Key recommendations for top-tier documentation 

Be specific and accurate: Document clinical findings in detail, including the severity, duration and impact of patient symptoms. Ensure you are signing your records as required. 

Support medical necessity: Ensure your notes clearly explain why services were provided and how they relate to the patient’s condition. 

Align codes with notes: Make certain that the codes selected accurately reflect the care and complexity documented in the patient’s health record. 

Use consistent language: Avoid ambiguity—consistent terminology strengthens the record and reduces questions from payers. 

Keep it patient-centered: Records should tell the story of the patient’s encounter, not just meet billing requirements. 

Check your electronic health record (EHR): When submitting documentation with an appeal, ensure that the full documentation is pulled from your EHR and submitted. 

Essential elements of a complete patient record 

To ensure a patient’s medical record is properly documented, doctors of optometry should adhere to the following: 

• The patient record must uniquely identify the individual with biographical information.
• The patient record must identify the name of the person providing care and the date of service.
• The patient record should contain an appropriate medical history including medications, conditions presently treated and the social determinants of health, which may impact the care of the patient.
• The chief complaint and reason for the visit should be clearly stated and expanded as needed.
• An appropriate physical examination based upon the needs of the patient should be documented.
• Laboratory and diagnostic testing that has been ordered or completed should be documented with a report.
• A diagnosis should be formulated as well as a treatment plan consistent with the diagnosis or clinical needs of the patient.
• Prescription and medication orders are clearly written and legible.
• Orders for additional testing or consultations should be properly drafted.
• Proper ICD-10 diagnosis codes and CPT procedure codes are listed, which correspond to the physical examination, testing, diagnosis and treatment plan