Improving the Coding Process with Current CPT Codes

A red stethoscope on marble countertop. the acronym CPT is written with arrows pointing to each word. Current, Procedural and Technology

According to MGMA Stat, nearly 70% of medical practices reported an increase in denials in 2021 with the average denial increase per practice reaching 17%. The reasons for these denials vary, however about 10% can be attributed to outdated or incorrect coding. With the most up-to-date CPT code set, healthcare providers can improve their internal processes.

High costs of incorrect codes

Although the majority of healthcare providers submit claims in good faith, two common coding mistakes can easily be misinterpreted as “fraud” or “abuse” by payers: Unbundling and upcoding.

Unbundling involves using multiple CPT codes for individual parts of a procedure, either due to a misunderstanding or in an effort to increase payment.
Upcoding involves using a more serious or more expensive procedure code than what was actually performed. Physicians found guilty of upcoding can be banned from insurance panels and programs.

For example, a psychiatrist who billed for 30- and 60-minute in-person sessions was actually only meeting with patients for 15-minutes to perform medication checks. When the upcoding was discovered, the psychiatrist was fined $400,000 and permanently excluded from taking part in Medicare and Medicaid programs.

Healthcare providers that don’t document procedures based on the most current CPT codes can easily and unknowingly upcode or unbundle and may find themselves in more trouble than they anticipated.

Improved Patient Care

When healthcare providers use current CPT codes, the services and procedures they provide to patients can be more accurately tracked, which is essential to identifying patterns and trends pertaining to patient health. This leads to more appropriate treatment plans and care outcomes and may highlight where a patient would need further care or support.

Additionally, more accurate information helps promote better patient engagement. Physicians and their staff spend less time addressing questions about outstanding billing and claims and more time actually caring for the patient. Provider reputation is significantly impacted by a practice’s ability to clearly communicate costs and care plans with patients.

Keep Staff Trained to Use the Latest CPT Codes

According to MGMA Stat, only half of healthcare organizations host annual training for CPT code updates. And for those that do train on the latest coding changes, email is the preferred training method.

It is imperative to host an annual evaluation of CPT codes and their usages among practice staff. Here are some proactive actions we recommend to ensure accuracy:

Assigning CPT coding reviews, updates, and training responsibilities to a team leader. 
Hosting a quarterly CPT codes review where leadership confirms usage guidelines.
Crosschecking denials with the latest CPT code file to troubleshoot and train.
Incorporating a CPT code updates component into medical coding training activities.

Quarterly meetings are particularly useful to highlight changes and opportunities for more training. They can also serve as a milestone to ensure that employee certifications are up to date and any courses are assigned

By using the most up-to-date CPT codes, practices can improve internal processes, ensure accuracy, prevent copyright infringement, and enhance patient care - important considerations for any healthcare provider.