[Editor's note: Since the Nov. 1 publication of this article, Aetna moved ahead with implementation of the differential beginning March 1, 2024.]
Thanks to advocacy from APTA and the American Occupational Therapy Association, major commercial insurer Aetna has reversed course — at least temporarily — and decided to hold off on implementing a 15% PTA payment differential that echoed the policy set in place by the U.S. Centers for Medicare & Medicaid Services. That win is tempered somewhat by an unrelated announcement from the insurer that it will stop covering many CPT codes that PTs have been paid for when used via telehealth.
The delayed implementation of the differential, which reduces payment by 15% for any services delivered "in whole or in part" by a PTA or occupational therapy assistant, came after APTA and AOTA sent a joint letter to Aetna asking for reconsideration of the decision.
"At a time when the country is facing unprecedented provider shortages in addition to untenable provider burnout, implementing this policy threatens to reduce patient access to therapy services," the organizations wrote. "Considering that provider reimbursement is not keeping pace with inflation and the costs of maintaining a practice, additional cuts to reimbursement … leave many clinic owners having to reduce their workforce by laying off OTAs and PTAs."
Aetna is describing the decision as a temporary hold on implementation. Kate Gilliard, APTA's director of health policy and payment, sees it as an opportunity.
"We were pleased that Aetna considered our perspective and took action," Gilliard said. "We plan on leveraging this pause to pursue more dialogue with Aetna around making a permanent move away from implementation of the differential."
The Bad With the Good
Aetna Announces End to Payment for Communication-Based Technology Codes and Some Telehealth Services Post-Public Health Emergency
Aetna stated that beginning Dec. 1, it would not cover E-Visits (CPT codes 98970-98972), Remote Evaluation of Patient Videos/Images (HCPCS code G2250), Virtual Check-Ins (HCPCS codes G2251 and G2252), or Telephone Assessment and Management (CPT codes 98966-98968), collectively known as communication-based technology services.
Additionally the insurer informed providers that beginning Dec. 1, it will no longer cover some services when delivered via telehealth. Among the codes for these services are some that may billed by PTs: 90901, 97129, 97130, 97150, 97163, 97164, 97542, 97763. Aetna will also not longer cover CPT code97535 as an audio only code.
Codes billed by physical therapists that will continue to be paid when delivered via telehealth and submitted with the appropriate modifier (GT or 95) are 97750, 97110, 97112, 97116, 97161, 97162, 97530, 97537, 97755, 97760, 97761 .
[Note: Aetna later clarified that this applies to employer-sponsored plans only.]
New Issue Identified When PTs and OTs Bill for Services on the Same Day
APTA is aware that some providers are seeing denials from Aetna when the combined billing of physical therapy and occupational therapy on the same day exceeds four units. Although Aetna policy indicates that a patient is entitled to a maximum of four units of each therapy per day, claims are being processed with a combined daily max of four units. APTA is working with representatives at Aetna to address this issue. Please email advocacy@apta.org if you are experiencing these denials.