Commonly Missed CPT Codes in 2024: Insights from Our Experience

Commonly Missed CPT Codes in 2024: Insights from Our Experience

Medical billing is a complex and detail-oriented field, and even experienced professionals can occasionally miss crucial details that lead to denied claims or incorrect billing. Incorrect CPT coding can result in denied claims, delayed payments, and, most importantly, significant financial repercussions for healthcare providers. Government programs such as Medicare and Medicaid have reported billions of dollars in improper payments annually due to coding errors and fraud.

HHS reports that Medicare Fee-for-Service improper payments totaled $31.23 billion in 2023. The common causes of those improper payments include insufficient documentation (62.8%), lack of medical necessity (15%), incorrect coding (11.6%), other reasons (6.9%), and no documentation (3.7%).

Our consulting firm has identified several CPT codes that are commonly overlooked in 2024. Based on our client audit findings, here’s a guide to these commonly missed CPT codes and actionable insights to ensure accurate usage.

52281: Cystourethroscopy with Calibration and/or Dilation for Urethral Stricture/Stenosis

• What It Covers: This code is used for cystourethroscopy procedures that include calibration and/or dilation for urethral stricture or stenosis in both male and female patients.
• Common Mistake: We’ve found that 52281 is often incorrectly used when the dilation was performed prior to the placement of the scope. In such cases, another appropriate cystourethroscopy code must be used.
• Actionable Insight: Always verify when the dilation occurred relative to the cystourethroscopy to ensure correct coding.

G0105/G0121 vs 45378: Colonoscopy CPT Code

• What They Cover: G0105 and G0121 are used for screening colonoscopies, while 45378 is used for diagnostic colonoscopies.
• Common Mistake: Some payors specifically require the use of G codes for screening colonoscopies, leading to billing issues if the incorrect code is used.
• Actionable Insight: Always check the payor’s requirements for screening colonoscopy coding to determine whether a G code or CPT code 45378 should be used.

10060: Incision and Drainage of Abscess; Simple/Single

• What It Covers: This code is for a simple or single incision and drainage of an abscess.
• Common Mistake: We frequently see that 10060 is billed without documentation of an actual incision. If an aspiration is performed instead of an incision, code 10160 is more appropriate if all documentation requirements are met.
• Actionable Insight: Ensure the documentation clearly indicates that an incision was made to properly use code 10060.

47562 and 47563: Laparoscopic Cholecystectomy CPT Code

• What They Cover: 47562 is for a standard laparoscopic cholecystectomy, while 47563 includes a cholangiogram.
• Common Mistake: Differentiating between 47562 and 47563 can be challenging, especially regarding whether the cholangiogram was utilized solely for visualization of strictures.
• Actionable Insight: Carefully review the operative report for clear documentation of the cholangiogram’s use. Refer to Coding Clinic for HCPCS 2Q 2023 for detailed guidance.

55866 vs 55867: Laparoscopic Prostatectomy CPT Code

• What They Cover: 55866 is for a laparoscopic radical prostatectomy, while 55867 includes a laparoscopic simple subtotal prostatectomy.
• Common Mistake: We’ve found that distinguishing between a simple subtotal prostatectomy and a complete resection of the prostate often causes confusion.
• Actionable Insight: Scrutinize the documentation to determine whether a simple subtotal procedure or a complete resection was performed to choose between 55866 and 55867. Refer to the Coders’ Desk Reference for detailed descriptions of both procedures.

Prevent Commonly Missed CPT Codes with Continuous Education

By being aware of these commonly missed CPT codes and understanding the nuances of their usage, you can improve your billing accuracy. We recommend regularly reviewing the latest coding guidelines and documentation requirements to stay current and compliant in your medical billing practices.

Our coding education services are created to assist both individual coders and corporate teams by offering courses on the latest CPT guidelines and coding updates. Whether you are an independent coder or part of a larger team, our training programs guarantee accurate code selection and compliance with coding practices. Explore our coding bundles for individual learners and coding bundles for corporate teams to begin your education journey today.