A patient is scheduled for surgery to repair an ankle fracture. All the authorizations are obtained for the relevant CPT codes. Then, on the operating table, the surgeon finds something surprising — two torn ligaments, which now need to be repaired, too.
“If you open up the patient and see something else, you are going to fix it. It’s what you have to do, in terms of providing quality patient care. But we also need to be sure we are doing what’s right for the hospital, too,” says Kristi Hall, senior financial navigation and training analyst at Cooper Health in Camden, NJ.
Surgeons are right to repair the torn ligaments. The problem is those CPT codes were not included in the initial authorization request. Patient access knew this recurring issue was causing some claims denials, but the actual prevalence of the problem was unclear. “The denial categories that come back from the payor aren’t too accurate,” Hall explains.
Health plans often indicated claims were denied because of a “noncovered service” or no authorization in place. Patient access suspected some denials were caused by incorrect CPT codes. There was no time to delve into the complex underlying issues of these denied claims. When the COVID-19 pandemic hit, elective surgeries were canceled, creating much-needed free time. “We decided to use the time wisely by doing some deep-diving into long-standing issues,” Hall reports.
The top question on the list: Why were so many orthopedic same-day surgery claims denied? Patient access staff reviewed several hundred cases for all the hospital’s institutes. Ultimately, the team decided to run a pilot program with Cooper Bone and Joint Institute because of a shared senior leadership structure.
After some digging, staff discovered misleading denial codes from payors had concealed the real problem. In sum, about 40% of denials involved CPT code changes. “It was mind-blowing. We knew we had to do something, but we didn’t know what,” Hall says.
Usually, staff appealed denials, but that took time and resources. “The appeal process is so difficult. It is so cumbersome. It takes months on end,” Hall laments.
Patient access started looking for a commercially available solution to prevent all the CPT code-related denials. Staff realized the ideal solution would be an automated tool that compares the CPT codes that were authorized to the CPT codes that were used. Unfortunately, no vendor offered anything like that. “We did all the due diligence. There is just no functionality to do this,” Hall says.
Next, patient access tried to learn how their peers were managing the problem; no luck there, either. “We participate in a monthly call of Epic users at other health systems. We are all having the same problem, but we found that nobody has really been able to do anything successfully about it,” Hall explains.
The department considered building fields into the registration system to compare CPT codes between what was ordered and what was used. That, too, was not feasible. Eventually, staff devised a mostly manual process, running a 10-week pilot test. Staff found a way to run reports on all the surgical cases with embedded CPT codes. “We were able to pull a report from our business analytics system to see the CPT codes that came off the order and what CPT codes were on the billing side,” Hall says.
Registrars investigated all cases over the 10-week period, uncovering nearly 200 mismatches. “We were able to get 12% of them approved, for a net revenue of over $100,000,” Hall reports. “It told us we were onto something.”
Health plan time frames for authorizations are important to consider in this process. Some plans allow CPT codes on the authorization to be changed for up to 10 days post-procedure; others allow only two days. “We prioritize cases to meet the requirements while still allowing time for proper coding to take place,” Hall notes.
Coders base CPT codes not on what was scheduled, but on the operative notes. Coders now go one step further. “They can go right to the authorization records and see what our insurance specialist authorized,” Hall says.
If it is a mismatch with what the operative notes say was used, then the coders assign a billing indicator to the account. “It then falls to our account-based work queue in Epic, and goes to our insurance specialist team, who knows that it is our high priority to work as soon as possible,” Hall says.
After completing the beta project in fall 2020, the team officially went live with the process change in January 2021. Ten weeks later, they had found more than 200 cases where a CPT code change occurred. Many claims have not been adjudicated — the payor has not decided whether to pay them in full, in part, or deny them altogether. “It is not yet possible to determine what the net revenue opportunity will be. But the gross opportunity on these cases is over $1 million,” Hall says.
The pilot included only same-day surgeries, not scheduled admissions for inpatients. For those cases, utilization management could fix mismatched CPT codes. For same-day surgeries, there is no opportunity to fix the incorrect CPT codes before the claim goes out. “It goes from the scheduler to the insurance specialist to the OR to the coder to the payer,” Hall says.
When the organization introduced price estimates in 2019, they did it slowly and methodically, starting with MRIs, then CT scans, then routine special procedures, such as cardiac catheterizations and interventional radiology, followed by ultrasounds. The same cautious approach is used with the new CPT code process. “We will go institute by institute so we can monitor it and make sure we are being successful,” Hall says.
Next, the initiative goes live at Cooper Neurological Institute. Patient access expects to gain even more revenue because of the high-dollar amount of each neurology case. “We are looking at ROI and whether we need FTEs as this gets bigger,” Hall shares.
The revenue loss caused by CPT code changes is nothing short of staggering. “It’s crazy to think what opportunity is out there for healthcare organizations across the country,” Hall offers. “All we had to do was stop and dig and work together as a team to find a solution.”
When it comes to CPT codes that change after service, “one of the biggest challenges is in the surgical space,” says Sarah Richards, senior project specialist for revenue cycle at Spectrum Health in Grand Rapids, MI.
The patient access department revamped some processes specifically to address the problem of changing CPT codes. High-tech imaging (CTs, PET scans, and MRIs) are scheduled before the authorization is obtained.
“This makes us somewhat unique. This cuts out the need to rework the authorization as we wait for the technician to finish protocolizing the order,” says Carson Buskard, manager of the central authorization team at Spectrum.
This gives technicians more leeway to change what is authorized (e.g., an MRI without contrast to an MRI with contrast). After the test is scheduled, but before the actual visit, staff check the correct CPT codes were authorized — at least for that point.
Changes during the procedure are inevitable, most often with colonoscopies. “Colonoscopy, by definition, is exploratory. So providers may find something unanticipated — and likely unauthorized,” Buskard observes.
The team finds CPT code mismatches by comparing the case log with what is billed, before the claim is sent. “If something were to change, we utilize a stop bill account. We do not allow the claim to go out the door,” Buskard says.
The same process is used for other surgical procedures. The goal is to correct the CPT codes early enough to avoid denial. “As long as we are ahead of the denial, we can generally get a retro authorization,” Buskard says.
With some payers, once the denial has taken place it is not possible to apply for a retroactive authorization. Instead, the hospital has to initiate the cumbersome appeal process.
Spectrum employs 85 authorization team members, a dozen of whom are specifically focused on surgery. Several employees monitor accounts for CPT code changes daily. “As long as we do it quickly enough, it may not be even considered a retro authorization,” Buskard explains.
Instead, the team can amend the authorization already on file. This saves weeks of time that otherwise would be spent appealing the denial. Some payors give a specific number of days where an amended authorization is possible. The bottom line is quick reaction is needed anytime CPT codes change. “We try to catch it as much in the moment as possible,” Buskard adds.