CPT code updates and past

Yearly, the American Medical Affiliation (AMA) updates the Present Procedural Terminology (CPT^®) codes to replicate the newest practices, technological developments, and regulatory necessities inside healthcare. The annual updates to the CPT code set play a basic function in aligning coding practices with developments in healthcare companies. As healthcare continues to evolve, staying present and compliant with these updates isn’t just a regulatory necessity, however a method to make sure high quality care supply whereas minimizing fraud, waste, and abuse (FWA).

This year’s revisions embody roughly 230 new codes, 49 deletions, and 70 revisions, representing a concerted effort to streamline coding practices and precisely replicate the evolving panorama of healthcare. As Health plan particular investigative models (SIUs) tackle new challenges in 2024, let’s break down a number of the most impactful updates in addition to different developments impacting healthcare FWA.

Key areas impacted by the 2024 CPT code modifications

Two key areas affected by the upcoming updates are CPT codes associated to Respiratory Syncytial Virus (RSV) immunizations and analysis and administration (E&M) codes.

Respiratory Syncytial Virus (RSV) immunizations

Among the many 2024 CPT code updates are the addition of 5 new codes associated to RSV immunizations. These new codes are product-specific and designed to boost the reporting accuracy and evaluation of RSV vaccinations, aiding in data-driven planning and allocation of sources. With these RSV modifications, suppliers might promote early entry to the vaccine in change for a deposit, charge, or for the affected person to pay out of pocket. Some plans might not cowl the vaccine, as IT is just not but included on the Facilities for Illness Management and Prevention (CDC) annual vaccine schedule, so members ought to concentrate on their protection up entrance. At present, the RSV vaccine is roofed below Medicare Half D and a few personal Health plans for adults 60 years and over.

Analysis and administration (E&M) codes

One other CPT code replace in 2024 impacts E&M codes, involving the elimination of time ranges from sure outpatient codes, reminiscent of 99202–99205 and 99212–99215. This replace may even affect add-on psychotherapy codes that can be utilized in tandem with E&M codes. This replace is being made with the intent of limiting the problem of “not possible days,” by which a supplier payments for extra timed companies than are doable inside their hours of operation. As a substitute, suppliers should meet a particular minimal time requirement for every code, aligning these codes with different E&M classes and aiming for standardization throughout outpatient companies.

Usually, insurers see not possible days inside psychotherapy however with potential upcoding of E&Ms, these time-based codes could be low-hanging fruit to research. If an E&M code is submitted alongside a further psychotherapy code (reminiscent of 90833, 90836, or 90838), the scientific file should each substantiate the distinctive E&M service and distinctly display the supply of psychotherapy. IT‘s essential that suppliers keep away from duplicating time spent on the E&M for the needs of psychotherapy billing. The documentation wants to obviously differentiate and assist every service independently.

When each are invoiced concurrently, the E&M code assumes the first place because the father or mother code, whereas psychotherapy serves as an add-on code. The time devoted to the E&M service can’t be used to validate the time allotted for psychotherapy for the reason that latter depends on time-based billing as an add-on code. To assist the E&M code, IT‘s important to offer a affected person examination and display medical decision-making. These modifications emphasize the necessity for correct documentation of service instances and doubtlessly affect coding for outpatient visits.

Different 2024 considerations in FWA

Along with CPT code modifications, 2024 might convey a rise in FWA round testing and weight loss prescriptions.

FWA in Ozempic, Wegovy, and others

In 2023, the excessive prescription charge of Ozempic and Wegovy, particularly inside Medicare and Medicaid, raised purple flags. The similarity between these medicine and potential misrepresentation of sufferers’ circumstances, resulting in unverified prescriptions for weight reduction somewhat than legit medical necessity, underscores the necessity for scrutiny in 2024.

The introduction of Zepbound, a brand new weight reduction drug akin to Mounjaro, may result in further challenges for the brand new 12 months. Whereas promising elevated weight reduction, IT necessitates strict adherence to particular standards for prescription protection. This stringent standards alignment with affected person diagnoses and check outcomes is important for insurance coverage approval. Plans should hold an eye fixed out for inappropriate prescription of the drug for sufferers who don’t qualify for weight reduction medicine.

Amid ongoing considerations about COVID-19 that can proceed in 2024, fraudulent billing for COVID-19 testing might persist. Figuring out discrepancies in billing practices—reminiscent of billing for in-person testing for sufferers situated distant, repeated testing inside brief intervals, or billing for assessments that weren’t requested nor obtained—will doubtlessly proceed to be important.

Residence infusion remedy

One other space of concern for 2024 is dwelling infusion remedy, a worthwhile service for homebound sufferers requiring intravenous or subcutaneous drug administration. This previous 12 months, we witnessed an elevated quantity of billing irregularities on this space. Put together for potential FWA by scrutinizing claims, evaluating supplier {qualifications}, and assessing documentation for correct service justification to detect overbilling or inadequate companies carried out.

Navigating the 2024 FWA panorama

Healthcare plans, suppliers, and coders ought to prioritize schooling and coaching classes to make sure a clean transition to the up to date CPT codes. Collaboration amongst coding professionals, clinicians, and administrative employees may help facilitate efficient implementation and compliance with the revised codes. The continual monitoring of reimbursement patterns and auditing for coding accuracy is essential to determine any potential discrepancies or areas for enchancment. Lastly, knowledge evaluation performs a pivotal function in figuring out discrepancies, validating companies rendered, and flagging doubtlessly fraudulent actions.