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FRAUD, WASTE, AND ABUSE

FWA Insights: Navigating 2023 CPT code changes

As of January 1, 2023, the American Medical Association (AMA) has begun implementing updated CPT® codes. For health plans, this means staying abreast of updates to ensure compliance with the latest coding structures and staying vigilant on the latest areas ripe for errors as well as fraud, waste, and abuse (FWA). Take a look at the most notable changes we’ve singled out for this year.

Evaluation and management (E&M) changes

The 2023 changes were planned and designed to bring most evaluation and management (E&M) categories under a single set of guidelines. These codes have been updated in several ways:

  • Reduction of key components from three to two. For E&M codes that previously required the three key components of patient history, examination, and medical decision making, the latest coding will be based on just two: a medically appropriate history or exam and the medical decision-making table or total time.
  • Adjustments in time-based billing. The language for time-based billing has been updated from “typical time” to “must be met or exceeded.” The time required for many services has also increased.
  • Observation and inpatient code updates. Observation codes have been deleted and inpatient codes have been updated to Hospital Inpatient and Observation Services.
  • Emergency visit updates. Emergency Department – Level 1 will now be considered equivalent to a nurse visit, and the code description states "may not require the presence of a physician or other qualified health care professional." We suspect this code will be utilized at a high volume raising the concern that patients will be billed for triage or registration-only with no provider interaction.

Abdominal hernia repairs

The AMA has implemented several updates to abdominal hernia repairs, including:

  • A new code family. CPT has created a new code family for abdominal hernia repairs: 49591–49618. Hernias will be measured by size of less than 3 cm to greater than 10 cm.
  • No global days. Global days will not be assigned to these abdominal hernia codes, since regular global days are 92 days and hernia repair often does not require this amount of time. Hospitals and care providers will be able to bill more accurately for each patient’s post-op journey.
  • New codes for sutures and staples. Two new codes for “suture or staple removal” or “suture and staple removal” have been created: 15853 and 15854, respectively. They must be billed with an E&M code. Plans should watch for any upcoding of E&M claims within this standard post-op period.

Proprietary laboratory analysis (PLA) codes

There are 70 new PLA codes for 2023, which is a considerable number. Here are a few of the most notable new codes as well as a few reasons that plans should pay them extra attention:

  • This code is for pain management, mRNA gene expression profiling. Due to its high cost, plans should keep an eye out for any suspicious billing.
  • This is a psychiatry test for mood disorders and requires gene expression profiling by RNA sequencing of 144 genes. Like other pain management services, this and other new codes should be monitored for FWA.
  • This code is a neurology test that focuses on autism spectrum disorders, providing a simple positive or negative result. It’s possible that this may appear in data not only from neurologists, but from other health providers. Plans should stay vigilant on scenarios where its use seems out of context.
  • This code is a definitive drug assay for 120 or more drugs per date of service. We predict a high probability that this code may be taken advantage of by bad actors due to its high reimbursement. Examine data sets early in the year billed by pain providers, the laboratory associated with it in Appendix O, and any other providers.

For many of these new PLA codes, the description may include the term “predictive risk score,” which means it’s a screening code. Plans should double check any provider manuals that their medical review team utilizes to determine if screening services are permitted. To help any other investigative research efforts related to these claims, plans can also refer to Appendix O, which provides specific details on the laboratory or manufacturer.

Other areas to look out for in 2023

As we enter the new year, take care to keep an eye on several other circumstances related to CPT codes that could have an effect on FWA.

Over the course of the year, plans should pay attention to the new behavioral health codes in the medicine section. Plans should also note that some of the nerve block codes now have imaging guidance bundled and should watch for ultrasound, fluoroscopy, and CT services bills with modifier 59.

Whether you’re looking for support or an entire outsourced team, Cotiviti can help your plan to stay on top of all CPT code and regulatory changes and catch FWA in its tracks. Cotiviti’s FWA solutions provide an end-to-end process for flagging, investigating, and preventing FWA within claims.

Our Claim Pattern Review is a prepay solution that works in tandem with Payment Policy Management to catch suspect patterns early, maximizing returns by preventing erroneous or wasteful claims payment. And FWA Management covers the latest in fraud detection and compliance for a robust solution that keeps your organization current and safeguarded against the latest schemes. Read our fact sheets to learn more.

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WRITTEN BY

Erin Rutzler
As vice president of fraud, waste, and abuse (FWA), Erin is responsible for the oversight and strategic direction of Cotiviti’s FWA solution suite. In her role, Erin has been integral in the development of Cotiviti’s FWA solutions over the past ten years. Serving as the company’s primary subject matter expert in investigations and FWA for compliance, client training, sales, and marketing activities, she regularly represents the company at industry conferences such as the National Health Care Anti-Fraud Association’s (NHCAA) Annual Training Conference (ATC).

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