Advocacy Alert: April

CPT Code Payments Problems Continue

By: Bobbie Celeste, PhD, OPA Director of Professional Affairs

Top Five:
1. Late payment by private insurers is in violation of Ohio’s prompt payment laws.

2. Significant rate cuts in connection with CPT code changes. APA Practice attorney Alan Nessman noted that sizeable cuts (10% for 90834) have been identified in NE, NY, OR, PA, TN and WA.

3. Companies paying the same amount for 90837 and for 90834. The parity question is whether companies are paying the same reimbursement for similarly paired medical/surgical CPT codes with a substantially different CMS valuation, e.g., different levels of office visits.

4. Companies not paying codes that have been valued by CMS (or at least not listing them in their fee schedule), e.g., 90837 or interactive complexity 90785) Note: CMS has NOT yet valued crisis codes 90839 and 90840 so these also may not be valued yet by insurers. If you use these, set your own fee.

5. Companies such as UBH/Optum requiring pre-authorization for 90837.

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