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Underutilized Codes: Paving the Road for Future Payment

We all have our go-to CPT codes. And then there are the codes that we avoid or overlook for various reasons. Maybe they aren’t covered by insurance, or maybe they pay so little, we don’t even bother with them. These are the underutilized codes. While your reasons for not using them make sense on the surface, digging a little deeper will unearth how you may be leaving potential money on the table.

Why are certain CPT codes underutilized?

There are various reasons for this. Two common ones are:

  • Insurance companies don’t pay for certain codes, so practices don’t bill them even though they are providing the service.
  • Providers are performing the service, but don’t know that there is a distinct, payable code for it.

It’s important to bill CPT codes even if insurance companies don’t pay for them.

Every year, the American Medical Association’s RVS Update Committee reviews current CPT codes and deletes those that are underutilized. Their reasoning is that if there are so few people billing certain codes, practices must not be providing those services. Therefore, they delete the codes in order to avoid having to spend the time and resources maintaining them.

According to PCC’s coding expert Jan Blanchard, CPC, CPEDC, it doesn’t matter if you are not getting paid by insurance carriers for a particular code; if you are performing the service, you should bill for it. Why? A big reason is that every time you bill a CPT code that doesn’t get paid, you are building a case in support of getting it paid in the future. When providers consistently bill for codes that don’t get paid, payers realize that these services are being performed. Once a critical mass is reached, it will be less likely for them to continue denying payment.

The second reason to bill for codes even if they don’t get paid is that it’s simply good data entry. You’ll have a more accurate billing record of services rendered, and won’t have to go back and wonder if you provided a particular service or not.

Additionally, you are not forfeiting anything by billing something that won’t get paid. You can simply write it off.  In the words of Jan, “a write-off, is a write-off, is a write-off.” You are not losing anything by writing off a denied code. Granted, your adjustments will go up on your reports but that is perfectly ok. And in doing so, you will have concrete numbers to bring to contract negotiations. Reports showing the amount of money left on the table due to unpaid claims will become a bargaining chip for you in your contract negotiations with payers. That data is a gift to the decision makers. It allows them to clarify what services are actually being provided, and provides a reason for them to start paying.

PCC’s Dashboard tool can help identify your practice’s underutilized codes.

PCC’s Dashboard tool helps you to identify what codes may be underutilized in your practice in a measure called Coding Expertise: Underutilized Billable CPTs. Commonly underutilized codes include:

Apart from the earlier-mentioned reasons for codes being underutilized, other reasons can include:

  • There may be an order for a service, but it is not tied to a CPT code, and so it doesn’t get billed.
  • There may be a CPT code sent to the billing department, who then writes it off rather than submitting it because they know it won’t get paid.
  • The billing system may be configured to automatically write that CPT code off because it doesn’t get paid.

Making the effort to bill codes that typically get denied may not bring you money right now, but it sets the stage for getting you paid in the future. Rather than writing-off services that you know won’t get paid, consider billing those codes in order to provide evidence to payers that the codes remain viable and should be considered for payment.