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AetnaCommercial · Prior Auth · Newsletter · Pathology, Dermatology, Gastroenterology +8 moreMedium impact

OfficeLink Updates - October 2024 notices and reminders (PDF)

Effective date
Not stated in the notice
Identified
Jun 19, 2026

Summary

Already effective between September 2, 2024 and January 1, 2025: precertification is required for Winrevair, Hercessi, Imdelltra, Rytelo, Yesafili, Opuviz, Ahzantive, Piasky, Kisunla, Yimmugo, Nypozi, Bkemv and Epysqli, and precertification is no longer required for Medicare members for Durolane, Euflexxa, Synvisc, Synvisc-One, Firmagon, Eligard and Zarxio effective October 1, 2024. Effective January 1, 2025, pathology codes 88300-88309 and 88331-88334 deny when billed on the same date of service as Mohs micrographic surgery codes 17311-17315, professional claims with a PC/TC indicator of '= 5' are not payable for hospital inpatients or patients in a hospital outpatient department, and Cologuard performed within one year after a completed colonoscopy will be denied. Also effective January 1, 2025, pharmacogenomic panel claims for Medicare members must be billed with CPT 81418, and Aetna International stateside members with a United States service address join the Enhanced Clinical Review Program for commercial members.

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What to do

Action · 10 steps
01Already effective on the dates stated (historical, check current applicability before acting): Precertification must be requested at least two weeks in advance and must include the actual date of service.
02Billing team: submit most precertification requests online through the Availity provider portal, or through the practice's EMR system if it is set up for electronic precertification requests, and use the Search by CPT code function on the Precertification Lists page to check whether a code requires precertification.
03Billing team: submit specialty drug precertification for commercial or Medicare members through Novologix on Availity.
04Billing team: pathology codes 88300-88309 and 88331-88334 billed on the same date of service as Mohs codes 17311-17315 will deny, and additional reimbursement may be allowed with evidence of a separate lesion.
05Billing team: professional claims with PC/TC indicator '= 5' will not be payable for hospital inpatients or patients in a hospital outpatient department.
06Billing team: for commercial members, H2017, H2019 and H2030 are allowed up to 16 units (4 hours), and units billed above 16 rebundle into the per diem code H2018, H2020 or H2031 for that date of service.
07Billing team: Cologuard performed within one year after a completed colonoscopy (CPT 45378-45398 or G0121) will be denied.
08Billing team: for Medicare members, pharmacogenomic panels must be billed with CPT 81418 as appropriate, and unbundled codes 81225, 81226 and four additional molecular pathology CPT codes rebundle into 81418, with modifier 59 not overriding this edit.
09Billing team: expect new claim edits from the Claim and Code Review Program, view them on the Availity provider portal, and use the code edit lookup tools with your Aetna provider ID number.
10Medical records may be requested for high-dollar claims, implant claims, anesthesia claims and bundled services claims.

Codes mentioned

J3490J3590C9399J9999J0175J7318J7323J7325J9155J9217Q51018830088309883318833417311173154537845398G0121H2017H2019H2030H2018H2020H2031814188122581226

Original notice

OfficeLink Updates - October 2024 notices and reminders (PDF)
aetna.com · Always check the source before changing claims.
View original ↗

Related changes

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Related policy hubs

Aetna policiesPathologyDermatologyGastroenterologyPharmacyOncologyOphthalmologyPulmonologyHematologyNeurologyNephrologyAllergy & ImmunologyCode J3490Code J3590Code C9399Code J9999Code J0175Code J7318Code J7323Code J7325Code J9155Code J9217Code Q5101Code 88300Code 88309Code 88331Code 88334Code 17311Code 17315Code 45378Code 45398Code G0121Code H2017Code H2019Code H2030Code H2018Code H2020Code H2031Code 81418Code 81225Code 81226

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