Private Payer Resource Center
Private payer policy updates
Dermatologists face a complex, ever-changing health care system, especially with third party payers. Use this guide to find out which insurer’s policy decisions will affect your practice.
E/M downcoding
Carriers will review claims from clinicians who are identified as coding at a higher E/M level as compared to their specialty peers. Some carriers are using proprietary algorithms that may incorrectly link specific diagnoses to certain levels of E/M, triggering claim edits within their claim processing systems. If, based on their internal claim review process, the carrier deems that the diagnosis reported does not support the E/M code level submitted on the claim, the carrier may:
Deny the claim and request resubmission of the claim with the appropriate E/M level;
Hold the claim and request documentation supporting the E/M level billed; and/or
Adjust reimbursement to reflect the lower E/M level supported by the diagnosis on the claim.
Insurers:
Aetna
Anthem
UnitedHealthcare
Tips to minimize a claim review
Make sure that the documentation supports the reported diagnosis and E/M level of service.
Include all pertinent ICD-10-CM codes to report diagnoses affecting the patient and medical complexity of the encounter.
Follow the carrier’s dispute resolution process (including submission of documentation with the appeal).
AAD resources
The AAD has a number of resources to guide dermatology practices in appropriate documentation and coding as well as effectively appeal inappropriate downcoding.
E/M coding: Choose between 2020 and 2021 E/M coding sets.
E/M coding tools for guidance on selecting the most appropriate E/M code for office encounters.
Successful documentation tips that withstand an audit.
Coding questions may be submitted to coding@aad.org.
Contact privatepayer@aad.org to report payer issues or if you have questions on private payers.
Modifier 25
E/M reduction
When an evaluation and management (E/M) code with modifier 25 and a procedure code having a 0-, 10-, or 90-day post-operative period are billed by the same clinician for the same date of service, plan will compensate the E/M service at specified percentage of the otherwise allowed amount.
Insurers:
AmBetter
Blue Cross Blue Shield of Kansas
Blue Cross Blue Shield of Rhode Island
Centene
Harvard Pilgrim Health Plan
HealthNet
Oscar
Tufts Health Plan
Global period
Payers are targeting suspected inappropriate use of modifier 25 through broad policies or targeted denials of high utilizers, post payment audit, and recoupment. When an encounter containing evaluation and management (E/M) code with modifier 25 has overlapping diagnosis as a previous encounter within a specified period of days, plan will deny reimbursement for the E/M portion of claim.
Insurers:
Anthem
Healthfirst
Learn more on AADA advocacy on payer modifier 25 payment reduction.
Modifier 25 Educational Tool
Download a PDF of the Academy's tool designed to help dermatologists understand modifier 25.
Access the PDFPrior authorization
Place of service
Requirement that a practice utilizing the outpatient hospital Place of Service (POS) code receive prior authorization when performing outpatient surgical procedures. If the outpatient hospital POS is determined not to be medically necessary, the claim could be denied.
Insurers:
UnitedHealthcare
AAD Setting Up to Succeed in Payer Contracting Webinar
Access the Academy's webinar on payer contracting and see other resources related to private payers.
Additional Academy resources
Use the Academy’s appeal letter tool to streamline administration.
Learn more about the Academy’s advocacy for dermatologists and their patients with private payers.
Access the Academy's resources on best use of modifier 25, which is often flagged by payers.
