Q3 Industry Updates – News You Can Use

Welcome to a round up of relevant news that piqued my interest over the past 60 days:

Select Aetna Updates 

• Aetna announced that effective September 1, 2021, it will no longer pay for professional services performed in a hospital setting for technical-only procedure codes. The CMS Physician Fee Schedule lists these codes as diagnostic only. They do not have a related professional code. Note: This is subject to regulatory review and separate notification in Washington state.​

• Also beginning September 1, 2021, Aetna will now require authorization for its enhanced clinical review physical medicine program for telehealth services. This affects members in its fully insured commercial and Medicare Advantage HMO/PPO Aetna products in: DE, NJ, NY, PA, and WV.

• Information on how to get preapproval can be found on the Magellan Healthcare portal. If you have questions, call National Imaging Associates at 1-866-842-1542.

• Aetna members can now talk with InformedDNA genetics experts from their homes. Flexible appointments are available by phone or video. Genetic tests are available for many reasons:

• Diagnosing inherited diseases
• Assessing the risk of passing an inherited disease to children
• Predicting risk of developing a disease
• Predicting response to medicine

• Genetic counseling is also available to help patients understand and adapt to the medical, psychological and familial genetic aspects of disease. If you have questions, contact InformedDNA at Info@InformedDNA.com, 1-800-975-4819, or https://informeddna.com/physicians/refer-a-patient/.

• You can access Medical Clinical Policy Bulletin Updates including HIV Drug Susceptibility and Resistance Tests, Antibody Tests for Neurologic Diseases, BRCA Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy, and may more at https://www.aetna.com/health-care-professionals/clinical-policy-bulletins/medical-clinical-policy-bulletins/changes.html

• There is a Clinical, Reimbursement, and Administrative Policy Update for the Frequency Editing (R34) policy. The update states that Cigna will deny any units of service that exceed the MUE limits for laboratory services billed with CPT codes 83921, 86332, 86353, and 87798. In addition, modifiers will not be allowed to override MUE limits for these codes.

• An updated Medical Coverage Policy, Ambulatory External and Implantable Electrocardiographic Monitoring, is now in effect addressing the use of ambulatory electrocardiographic monitoring in the evaluation of patients with suspected arrhythmias, unexplained episodes of syncope and/or cryptogenic stroke. The coverage has been expanded to include external event monitors and mobile cardiac outpatient monitoring.  In addition, new policy statements were added to address replacement of implantable electrocardiographic event monitors and self-monitoring devices and software.

• COVID-19 Interim Billing Guidelines were updated effective July 1, 2021. The policy was updated to include new HCPCS codes M0201 (COVID-19 vaccine, home administration), Q0244 (casirivimab and imdevimab 1200mg injection), M0244 (casirivimab and imdevimab home infusion), M0246 (bamlanivimab and etesevimab home infusion), and M0247, M0248 and Q0247 (sotrovimab product and administration). The HCPCS M0243 code description was also revised to include injections.

• The Medical Coverage Policy for Whole Exome and Whole Genome Sequencing was updated to include important changes in coverage criteria, and establishing separate disease-specific criteria statements for clarity for epileptic encephalopathy, fetal testing, testing for nonsyndromic hearing loss, and phenotype suspicious for a genetic diagnosis disease. In addition, two criteria sets were added for indications considered not medically necessary (NMN) including whole exome sequencing (WES) testing, and fetus testing using WES.

• Several medical policies were updated, including Cardiac Event Monitoring, Carrier Testing for Genetic Diseases, Chromosome Microarray Testing (Non-Oncology Conditions), Genetic Testing for Cardiac Disease, Hereditary Cancer, and Neuromuscular Disorders, among others.

• A commercial reimbursement policy bulletin was issued announcing the delay of the implementation of a change to the Provider-Based Billing Policy, Professional and Facility until September 1, 2021.

• In early July, United Healthcare announced its 2021 – 2022 preferred lab network expansion. Effective July 1, 2021, for commercial, Community Plans and Medicare & Retirement Plan members, the following laboratories have been added to the United Healthcare Preferred Lab Network:

• Finally, the laboratory test registration requirement was delayed. See our recent post on this topic for more details.