What are CPT® Codes, and why does your medical practice need experts in them? The Current Procedural Terminology (CPT®) is a trademarked set of codes accepted by Medicare and Medicaid. They offer health care professionals uniform language for medical reimbursements. They can streamline reporting, increase accuracy and reduce inefficiencies.
Owned by the non-profit organization, The American Medical Association (AMA), CPT® Codes may only be used by AMA members, though they are required to bill Medicare and Medicaid, along with all other insurance companies.
CPT® Codes are updated, edited and changed every year. In the 2023 code set, every section of the CPT® guidelines had changes, except for anesthesia. The areas with the most significant changes were hernia repairs, Covid-19 vaccinations, evaluation and management (E/M) and pathology.
If your medical billing department, in-house or outsourced, does not stay current on updated CPT® Guidelines, be prepared for problems. There are three areas to be concerned about. A) You may increase the number of denials because the wrong code was used, B) You may be leaving revenue on the table because you did not know you could bill for services you did perform, C) You could mistakenly commit fraud by using codes incorrectly in a manner to gain additional revenue.
Experts in Medical Billing, including knowing the new changes to CPT® Codes, can make a crucial difference in 3 key areas.
- Fewer Insurance Claim Denials - Insurance companies have an obligation to cover the cost of services that are “usual, customary and reasonable” (UCR). CPT® and medical billing experts can use independent references to prove your rates were UCR rates. Additionally, using correct CPT® codes prevents denials, or can overturn denials into an appeal. However, incorrect CPT® codes in billing will cause denials and establish a trend to deny claims for a practice.
- Proving Damages – When medical services are provided in conjunction with injuries from an accident, lawyers, mediators and juries can become involved. Having CPT® experts in medical billing can give defense for the price of services charged. Opposing attorneys may question each charge, but a Medical Billing expert can give a proper and legal defense for each charge.
- Detecting Fraud – In many instances, more than one medical practice may be involved in the treatment of a patient. If one of the medical practices is suspected of duplicate-billing, overbilling, or billing for services not rendered, it is important that your billing experts can show that the alleged fraud is not connected to your practice. Being able to show what fraudulent billing looks like and how your billing is not like that, can save your practice from many legal issues and headaches.
Physicians need to know that legal liability untimely falls to the provider whose National Provider Identifier (NPI) was used for the billing of services rendered. The physician’s signature on a claim attests the services billed were necessary and reasonable.
Unfortunately, there is a legal precedent that if a medical biller commits fraud, the physician is eligible to lose their license, even if they were unaware of the fraud. This has only occurred with in-house medical billers.
When a business, such as Medek RPM, employs CPT® Coding experts, you minimize your risk in denials, unbilled services, and possible fraud. Experts can save your practice time and expenses, through proper billing. When you are able to utilize these experts and increase revenue to your practice through RPM (remote patient monitoring), both you and your practice will benefit.