July 5, 2005

Aetna Issues New Reimbursement Policy
As of June 15, Aetna will reimburse each of the add-on codes wall motion study (78478) and ejection fraction (78480 ) when billed with a myocardial perfusion imaging study (78460-78465). Aetna recently sent an update in its provider newsletter explaining the new reimbursement policy.

ACC has confirmed with Susan Millerick and Stacie Watson, Aetna’s spokesperson and Head of Clinical and Reimbursement Policy Administration, respectively, that the system change will allow reconsideration (retroactive reimbursement) of claims, based on the May 14 implementation date, for 180 days (six months) from the date of the initial claim determination (Aetna’s date) provided that the claim was submitted within the timely filing limits, or 60 days for an appeal if reconsideration has previously occurred, provided appeal rights still exist for the claim. For more information, contact Mia Thomas of Payer Advocacy at 301-581-3418.

AMA Adopts Pay-for-Performance Guidelines
The American Medical Association (AMA) House of Delegates has adopted comprehensive guidelines for pay-for-performance programs. The guidelines cover quality of care; the patient/physician relationship; physician participation; physician data and reporting; and program rewards. While the AMA has tried to forge consensus among the physician community on a core set of guidelines and principles, a number of surgical societies concerned about the Congress’ interest in moving to a pay-for-performance system as early as 2008 amended the resolution so it states that the AMA oppose any pay-for-performance programs unless they meet the guidelines and principles. Some groups, including the ACC and the American College of Physicians (ACP), are concerned about the hard line that effectively has been drawn by requiring that all the principles and guidelines be met. “This is going to make it very difficult for the AMA to engage constructively in influencing what comes out of Medicare,” said Robert Doherty, senior vice president of ACP.

Medicare Pay-for-Performance Bill Unveiled
Senate Finance Committee Chairman Charles Grassley, R-IA, and the committee’s ranking Democrat, Senator Max Baucus, MT, have introduced a bill to encourage reporting of quality data. The legislation would allow the secretary of the Department of Health and Human Services (HHS) to first reward providers when they report quality data and then, again, when they achieve quality improvements. The bill would also authorize a national healthcare information technology pilot program. The ACC is currently reviewing the legislation.