Aetna: Billing Modifiers 25, 59, and X series (NY and NJ)

New York:

Starting from December 1, 2020, Aetna will apply new edits for billing modifiers 25, 59, and X series in New York for fully insured membership claims. While edits are already applied for self-insured membership claims, the new edits are part of the Aetna Third-Party Claim and Code Review Program and will apply prior to finalizing claims for professional services and outpatient facilities. In their words: “We will review the service, service history, changes in condition and diagnostic tests to determine if the services billed with modifiers 25, 59, and X require separate payment. We will allow charges for covered services not subject to the coding review.”