Receiving payment for patient services rendered has everything to do with the entering the right Current Procedural Terminology (CPT) codes. “CPT codes represent our pathway to payment,” says Tonia Ferguson, senior director of patient access at Boise, ID-based St. Luke’s Health System.
Identifying which services were provided to patients sounds like an easy task. “But it can be very challenging to ensure the correct CPT codes are selected,” Ferguson notes.
For patient access, it all starts with collecting accurate information from the beginning. “Our role in the creation of a clean claim is to first provide a foundation of correct patient demographic and plan selection,” says Ferguson, adding that thanks to standardized processes and technology, “CPT codes can be managed.”
There are many valid reasons why an incorrect CPT code is used when a test is ordered or surgery is scheduled. “CPT code changes are a normal and unavoidable part of healthcare,” Ferguson observes.
A provider does not always know in advance if contrast will be required for an MRI. A surgeon intends to perform procedure A, but while in the operating room, procedure B is required. “Not using the correct combination of codes leads to denials and possibly an unhappy patient,” Ferguson cautions.
There are times when CPT codes are not added at all. Either way, revenue cycle staff run into problems with denied claims. This is especially problematic if the patient received an estimate of cost based on what the provider ordered. “It’s important we deliver very clear information regarding an estimate and its ability to change,” says Ferguson, adding that patients could end up paying more than they planned on.
If a claim is denied due to incorrect CPT codes, revenue cycle staff do not just accept it. Some detective work is needed to discover the reason why. “We spend a good deal of time and resources trying to track down its cause,” Ferguson says.
First, staff search the patient’s medical record for any authorization information missing from the claim. “We contact the provider to fill any gaps,” says Ferguson, noting attempts are made to obtain a retroactive authorization. “Possibly, an appeal will be submitted. This can take months to resolve.”
To avoid rework on the back end, patient access stays on top of payer rules. “We have tools and processes in place to identify and handle code changes in a timely manner,” Ferguson reports.
One such tool is real-time authorization, conducted before the patient presents. “We address any authorization gaps or errors in what was ordered or entered by the provider,” Ferguson adds.
To move this work even farther up the line, St. Luke’s is building a new estimate tool. Staff will be able to provide an estimate to patients before a procedure is even scheduled. “It also puts the control of creating an estimate in our patients’ hands via a self-service portal,” Ferguson says.
This helps with erroneous CPT code entry. “For an estimate tool to work, it requires standardized CPT code mapping to specific procedures,” Ferguson explains.
Certain procedures require multiple CPT codes. Knee replacement surgery and MRIs with contrast are two common examples. The tool factors in these code groupings. “This can be changed once the actual procedure occurs, of course,” Ferguson says. “But it helps build a correct foundation.”
Staff create the estimate, gain authorization, and help patients with a payment plan if necessary, all based on the correct CPT codes. “All of this preservice effort helps to ensure a clean claim in the end,” Ferguson says.