If Not Listed Above, Then the Undefined Procedure Rate Will Be Applied

Codes / Provider types affected / What’s changing
30462, 30465, 35875, 35876, 36831, 58546 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 7 (AEG7)
Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).

If contract contains an Ambulatory Surgery – Aetna Enhanced Grouper: Category 7 rate it will be applied; if not, then the Ambulatory Surgery Default Rate will be applied

30462, 30465, 35875, 35876, 36831, 58546 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Coventry Enhanced Grouper: Grouper 7

If not listed above, then the Undefined Procedure Rate will be applied.

If the contract contains none of the above provisions, the relevant terms of the contract will rule.

19298, 21127, 38570, 43653, 50945, 50947, 50948, 54690, 54692, 55550, 55873, 58545, 58550 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 6 (AEG6)
Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).

If contract contains an Ambulatory Surgery – Aetna Enhanced Grouper: Category 6 rate it will be applied; if not, then the Ambulatory Surgery Default Rate will be applied

If not listed above, then the Undefined Procedure Rate will be applied.

If the contract contains none of the above provisions, the relevant terms of the contract will rule.

44370, 44379, 49566, 52647, 52648, 52649, 58563, 62287 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 5 (AEG5)
Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).

If contract contains an Ambulatory Surgery – Aetna Enhanced Grouper: Category 5 rate it will be applied; if not, then the Ambulatory Surgery Default Rate will be applied

44370, 44379, 49566, 52647, 52648, 52649, 58563, 62287 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Coventry Enhanced Grouper: Grouper 5

If not listed above, then the Undefined Procedure Rate will be applied.

If the contract contains none of the above provisions, the relevant terms of the contract will rule.

29862, 49501, 49507, 49520, 49521, 49553, 49557, 49561, 49572, 49582, 49587 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 4 (AEG4)
Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).

If contract contains an Ambulatory Surgery – Aetna Enhanced Grouper: Category 4 rate it will be applied; if not, then the Ambulatory Surgery Default Rate will be applied

If not listed above, then the Undefined Procedure Rate will be applied.

If the contract contains none of the above provisions, the relevant terms of the contract will rule.

29848, 29893 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 (AEG3)
Code will remain assigned to Endoscopic procedures (ENDO) and Ambulatory Surgery: Default Rate (DEFAULTSUR).

If contract contains an Endoscopic procedure rate, there will be no change

If contract does not contain an Endoscopic rate, but has an Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 rate, then the Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 rate will be applied

If the contract contains neither an Endoscopic rate or an Ambulatory Surgery – Aetna Enhanced Grouper Category 3 rate, the Ambulatory Surgery: Default Rate will apply.

36475, 36478, 47556, 55875 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 (AEG3)
Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).

If contract contains an Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 rate it will be applied; if not, then the Ambulatory Surgery Default Rate will be applied

52282 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 (AEG3)
Code will remain assigned to: Minor Surgery: All Surgery (MINSURDEF); Minor Surgery: Medicare Groupers (MINSURMED) and Ambulatory Surgery: Default Rate (DEFAULTSUR).

If contract contains any of the following rates: Minor Surgery: All Surgery; or Minor Surgery: Medicare Groupers there will be no change.

If contract does not contain any of the above Minor Surgery rates but does contain an Ambulatory Surgery: Aetna Enhanced Grouper Category 3 rate, then the Ambulatory Surgery: Aetna Enhanced Grouper Category 3 rate will be applied

If the contract contains none of the Minor surgeryrates or an Ambulatory Surgery – Aetna Enhanced Grouper Category 3 rate, the Ambulatory Surgery: Default Rate will apply.

58565 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 3 (AEG3)
Code will remain assigned to: Surgical Hysteroscopy (HYSTERINF) and Ambulatory Surgery: Default Rate (DEFAULTSUR).

If the contract contains a Surgical hysteroscopy rate, there will be no change

If the contract does not contain a Surgical hysteroscopy rate but does contain an Ambulatory Surgery: Aetna Enhanced Grouper Category 3 rate, then the Ambulatory Surgery: Aetna Enhanced Grouper Category 3 rate will be applied

If the contract contains neither a Surgical hysteroscopy rate or an Ambulatory Surgery – Aetna Enhanced Grouper Category 3 rate, the Ambulatory Surgery: Default Rate will apply.

29848, 29893, 36475, 36478, 47556, 52282, 55875, 58565 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Coventry Enhanced Grouper: Grouper 3

If not listed above, then the Undefined Procedure Rate will be applied.

If the contract contains none of the above provisions, the relevant terms of the contract will rule.

45190 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 2 (AEG2)
Code will remain assigned to Ambulatory Surgery: Default Rate (DEFAULTSUR).

If the contract does not contain the above rate, the Ambulatory Surgery: Default Rate will apply.

45190 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Coventry Enhanced Grouper: Grouper 2

If not listed above, then the Undefined Procedure Rate will be applied.

If the contract contains none of the above provisions, the relevant terms of the contract will rule.

36476, 36479 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Ambulatory Surgery – Aetna Enhanced Grouper: Category 1 (AEG1)
Code will remain assigned to Endoscopic procedures (ENDO) and Ambulatory Surgery: Default Rate (DEFAULTSUR).

If contract contains an Endoscopic procedure rate, there will be no change

If contract does not contain the above rate, but has an Ambulatory Surgery – Aetna Enhanced Grouper: Category 2 rate, then the Ambulatory Surgery – Aetna Enhanced Grouper: Category 2 rate will be applied

If the contract contains neitheran Endoscopic rate nor an Ambulatory Surgery – Aetna Enhanced Grouper: Category 2 rate, the Ambulatory Surgery: Default Rate will apply.

36476, 36479 / Facilities including Acute Short Term Hospitals and Ambulatory Surgery Centers / Will be reassigned to Coventry Enhanced Grouper: Grouper 1

If not listed above, then the Undefined Procedure Rate will be applied.

If the contract contains none of the above provisions, the relevant terms of the contract will rule.

Recognition of Bill Types 142-149 for Hospital Outpatient Department (HOPD) Ambulatory Payment Classification (APC) pricing / Facilities including Acute Short Term Hospitals / Bill Types 142-149 will be assigned to the list of eligible bill types utilized for participating providers who are contracted with the Centers for Medicare and Medicaid (CMS) Hospital Outpatient Department (HOPD) Ambulatory Payment Classification (APC) payment methodology

When contracted with the APC payment methodology, these claims will begin pricing at this method and no longer at the contracted default outpatient rate.

J0640, J0641 / Facilities including Acute Short Term Hospitals, Free Standing Ambulatory Surgery Centers and Skilled Nursing Facilities / Will beremoved from All Other Drugs (HCDHPALLOTH).
Codes will remain assigned to All Drugs or Drug Agents without Specific Rates Set Forth Above or Herein (DEFALLDRUGS).

The All Other Drug rate will no longer be applied to these codes. The existing All Drugs or Drug Agents without Specific Rates Set Forth Above or Herein will begin to be applied.

If the contract does not contain an All Drugs or Drug Agents without Specific Rates Set Forth Above or Herein rate, the existing All Other Outpatient rate will be applied.

J0640, J0641 / Facilities including Acute Short Term Hospitals, Free Standing Ambulatory Surgery Centers and Skilled Nursing Facilities / Will beaddedto Chemotherapy Drugs (HCDHPCHEMCS, HCDHPCHEMO, and OPCHEMODRUG).
If the contract contains a Chemotherapy Drug rate, then this rate will be applied. If the contract does not contain a Chemotherapy Drug rate, the All Drugs or Drug Agents without Specific Rates Set Forth Above or Herein will continue to apply.
73706, 76497 / Facilities including Acute Short Term Hospitals, Ambulatory Surgery Centers, Children’s Hospital , and Diagnostic Radiology Centers / Will be assigned to CTSCAN (CAT Scan).
Codes will remain assigned to DIAGRAD, RAD, & RADHCPC (Radiology Services).
If a CAT Scan rate is present in the contract, the CAT Scan rate will be applied; if contract does not contain a CAT Scan rate, the existing Radiology Services rate will continue to apply.
Drug code groupings / Facilities / We are NOT changing the codes contained within drug service groupings.
However, we identified a system issue.
To correct the issue, the formatting of these codes require an internal change.
The following service groupings will be updated:

Drugs (DRUGS)
Chemotherapy Drugs (HCDHPCHEMCS, HCDHPCHEMO, and OPCHEMODRUG),
All Other Drugs (HCDHPALLOTH).
Chemotherapy & All Other Drugs (HCDHPALL, HCDHPALLWCS).

Effective 9/1/2017, we will remove any code ranges contained within these service groupings; each code will be entered individually instead.
Changes in compensation may occur, however we will not pursue any past overpayments.
Not Provided (NONCNT) / All Provider types / If a contract contains a service defined as Not Provided, when that service is billed today, it is manually priced at the All Other Outpatient Default rate, or the Inpatient Medical Surgical rate, based on the claim type. Following this change, the service will no longer be priced.

*Unless otherwise indicated all updates will be effective 09-01-17.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).