A recent suggestion to inform insurance plans about prior authorization using CPT codes was retracted last minute by its physician advocate after discovering that some medical coding already had prior authorization requirements in specific situations.
Original Proposal by Dr. Shteynshlyuger
Alex Shteynshlyuger, M.D., head of urology at New York Urology Specialists, had previously presented a plan based on time to make sure doctors are paid for time spent on prior authorization claims. He thought that the alterations would also decrease the quantity of insurance claims stipulations dictated by healthcare policy and restrict the number of appeals, which could result in improved patient results.
AMA’s Response and Proposal Retraction
After receiving the suggestion, the American Medical Association (AMA) told Shteynshlyuger that prior authorization is clearly stated in official descriptions for six medical codes. Shteynshlyuger had to retract the physician services proposal to make revisions and resubmit it at a later time.
CPT Code Descriptions and Prior Authorization
Every CPT code comes with a brief explanation of the visit or examination type. Extended descriptions found in authorization documents are also saved in databases available for purchase, although they are not frequently encountered.
“I have never seen a long description in my entire life,” remarked Shteynshlyuger.
AMA’s CPT Changes and Information Dissemination
Every year, the AMA releases a CPT Changes book detailing the changes made in the previous year. The company also offers an online data management system, and providers can collaborate with organizations such as Optum which are regularly updated with the latest changes. However, the majority of doctors are unaware of how to find or would not consider searching for authorization information in those descriptions.
The AMA allowed Shteynshlyuger to share them with the press. Short descriptions do not refer to prior authorization, unlike their inclusion in the longer descriptions.
He stated that the AMA CPT panel had recently updated the detailed description of the CPT codes for medical procedures and quietly included prior authorization in it. “I don’t know why physicians have not been informed yet.”
Billing for Prior Authorization
Billing for prior authorization is only applicable in specific situations under these CPT codes. In these situations, the codes specifically focus on same-day evaluation management appointments and the amount of time a physician spends finalizing the insurance claims. Billing done by prior authorization specialists or medical assistants will not be considered.
If all of these criteria are fulfilled, the reimbursement process of all the health insurance policies must adhere to the instructions.
Future Plans and AMA Updates
Shteynshlyuger plans to resubmit his proposal with “dedicated codes” as per the healthcare regulations. Once they are prepared due to numerous instances where CPT codes are not suitable for reimbursing physicians. Furthermore, CPT codes enable a more detailed examination of the impact of prior authorization, ultimately enhancing the delivery of healthcare over time. In its CPT handbook for 2021, the AMA updated the codes and guidelines for pre-approval of outpatient evaluation and management services.
AMA’s Support for Physicians
In a news release, the president of the AMA, Dr. Susan Bailey, said that the AMA is aiding doctors and healthcare groups in getting ready for the upcoming transition by providing reliable resources for forecasting the changes in operational, infrastructural, and administrative workflows.
AMA members can also utilize medical coding for assistance with coding and billing inquiries. It aids clinicians in challenging insurance claims and answering other daily inquiries.
Upcoming Resources from AMA
The organization in the recent proposal stated that the upcoming statements will be released on its website to assist physicians and coders. This will help them comprehend evaluation and management office visit codes when reporting work related to authorization requirements with the help of the CPT Assistant.
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FAQs
1. How are CPT codes being updated to reflect prior authorization requirements?
Ans: Some CPT codes now include prior authorization in their detailed descriptions, particularly for same-day evaluation management appointments and physician time spent on insurance claims.
2. Why was a recent proposal regarding CPT codes and prior authorization retracted?
Ans: The proposal was retracted when it was discovered that prior authorization was already included in official descriptions for six medical codes, necessitating revisions to the plan.
3. How is the AMA helping physicians adapt to changes in CPT codes related to prior authorization?
Ans: The AMA is providing resources to help physicians prepare for the transition, including updates to the CPT handbook and plans to release statements on their website to assist with understanding new evaluation and management office visit codes.
