For patient access, denials caused by CPT code changes are frustrating. It happens most often with diagnostic radiology services and outpatient surgery procedures.
“The ordered and preauthorized service suddenly changes because of patient history, medical necessity, or some other clinical indicator that pops up immediately prior to or during the service,” says Lisa Walter, manager of education content development at nThrive.
CPT codes change if patients reveal something that is not in the medical record, or suffers an unexpected complication. Similarly, codes might change if the provider discovers an unforeseen issue while performing a procedure. “There are so many reasons why this happens,” Walter notes.
When CPT codes change, it means the prior authorization is no longer valid. For the patient, that means additional out-of-pocket costs. For the hospital, it means claims denials.
Another common example is a patient scheduled for an MRI without contrast. The radiologist finds out about a previous surgery, necessitating an MRI with contrast to obtain better images. Because an MRI without contrast was preauthorized, the hospital likely is not going to be paid for the needed test. “At that point, radiology has to involve patient access,” Walter says.
Patient access can intervene to stop the unauthorized test, assuming it is not emergent or urgent — or find out if the patient wants to go forward anyway. “Regardless of what the patient decides, it’s so important that patient access is involved,” Walter stresses.
Patient access expertise makes all the difference on whether the hospital is paid, and how quickly. Possibly, the health plan will agree a new authorization is unnecessary — as long as the clinical records are sent with the claim.
If that is not the case, then the patient either has to reschedule the test, or sign a financial responsibility form. “If patient access is unable to be involved in the process, things can go wrong,” Walter observes.
If a patient is scheduled for outpatient surgery for an excision of a malignant lesion of a certain size, the surgeon’s office preauthorizes that specific procedure. However, once the surgeon starts the procedure, she discovers the lesion is much larger.
The surgeon, based on clinical decision-making and medical necessity, performs a different procedure to remove the larger lesion, all based on what is best for the patient. “This new procedure is documented in the record and coded. The CPT code ultimately assigned was not the one preauthorized,” Walter says. These are some possible outcomes:
• In the best-case scenario, the new CPT codes are caught, fixed, and the hospital is paid. “Some systems run reports at the end of every day that cross-reference prior authorizations with coded procedures and identify mismatches,” Walter says.
Ideally, patient access coordinates with the billing department to place the claim on hold, giving everyone time to update the codes.
• The procedure is performed without authorization. Later, the claim is denied for no authorization, and the hospital writes it off.
• Nobody notices the wrong CPT codes until the situation is too late. First, the payor denies the claim, which takes anywhere from 20 to 45 days. Then, the hospital appeals, adding another 30 to 90 days to the payment time.
• Some claims are denied, but the payor allows a retroactive authorization. This adds another seven to 30 days to the process, but the hospital does eventually receive payment.
“Without patient access involved, it could take over 60 days just to collect from the health plan and additional time to collect from the patient,” Walter says.