CPT Code for Prior Authorization May Still Happen –

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Proposal would cover more than existing codes for limited situations

by
Joyce Frieden,

Washington Editor, MedPage Today


July 8, 2024

Remember that physician who wanted to develop a Current Procedural Terminology (CPT) code for prior authorizations? It hasn’t happened yet, but he hasn’t given up on it, either.

In May, Alex Shteynshlyuger, MD, a New York City urologist in solo practice, spoke with MedPage Today about a proposal he was developing for a new CPT code that would be used to bill insurers for the time physician practices spend obtaining prior authorizations.

Under the current system, “there’s a problem of incentives and costs,” he explained at the time. “When a medical office does prior authorization, there’s a disincentive to do that — I take money out of my pocket to do it. I’m not compensated for that in any way.”

On the other hand, “health insurance companies have an incentive to [require] prior authorization, because the cost to them is minimal,” added Shteynshlyuger, who studied economics as an undergraduate. He referred to a recent ProPublica story in which a doctor said she was fired from her job as a prior authorization reviewer at Cigna because she spent too much time reviewing requests. The article examined reviewer dashboards, which listed “a handle time of 4 minutes for a prior authorization. The bulk of drug requests were to be decided in 2 to 5 minutes. Hospital discharge decisions were supposed to take 4½ minutes.”

Shteynshlyuger had originally planned to submit his CPT code proposal for discussion at the American Medical Association (AMA)’s CPT Editorial Panel meeting in May. But he withdrew it after finding “the best kept secret in healthcare hidden in plain view,” he told MedPage Today in a recent phone interview.

“There was already an existing way to bill for prior authorization in a very limited number of situations,” he said.

“It looks like 3 to 4 years ago, the AMA CPT Panel revised the description of codes 99203 (office or other outpatient visit for the evaluation and management of a new patient which requires a medically appropriate history and/or examination and low medical decision making), along with 99204 and 99205, as well as CPT codes for follow-up visits (99213, 99214, and 99215),” he said. “What that means is when using these CPT codes, you can bill for prior authorization.”

Specifically, the code descriptions say that doctors can bill for time spent when they, “in concert with the clinical staff, complete prior authorizations for medications and other orders.”

However, there are several problems with using these codes to bill for prior authorization, Shteynshlyuger noted. For one thing, “these codes can only be billed [for work performed] on the day when you’re seeing the patient in person, either physically or by telemedicine. But most prior authorization is not done on the day the person is seen.”

Instead, the doctor might give the patient a prescription and then the insurer informs them a few days or a week later that prior authorization is required for it, “so in those situations [prior authorization] cannot get billed for,” said Shteynshlyuger. “And it’s not clear whether other CPT codes can be used to bill for that situation.”

Then there is the problem of billing for medical complexity versus billing for time, he said. “There are two ways of billing for CPT codes: one is by time — how many minutes you spend on something — and the other is complexity, that is the level of medical decision-making [involved], based on established criteria. So what happens if you see a patient and bill for the visit using medical decision-making but then spend 40 minutes on the phone with the insurance company doing prior authorization? How do you combine the two components? There is no answer to that.”

And there is a third issue: “You can only bill for the time used by the physician,” not a physician assistant or office staff members, Shteynshlyuger added. “In my office, for example, I don’t have a dedicated person who only does prior authorizations but I have a few trained people who do prior authorization plus their other tasks.”

He said he’d heard that the AMA CPT Panel is planning to release a guidance document to explain in which situations these codes can be used to bill for prior authorizations, “but it’s not clear what the timeline is.”

“I think there’s still a role for dedicated CPT codes for prior authorization, for two reasons,” said Shteynshlyuger. One is that existing CPT codes may not allow full time for capture of time spent on prior authorization. The other reason is that prior authorization-specific CPT codes would make it easier to study their effect on the healthcare system.

Shteynshlyuger said he will be revising his proposal to address some of these issues. “If you submit the proposal and it doesn’t get accepted, you cannot resubmit for some period of time; you need to go in with guns blasting,” he said, although this likely wouldn’t happen in time for the next CPT panel meeting.