D. J. Selzer1, M. A. Al-Haddad2, M. A. Schacht4, J. K. Hathaway5, J. C. Kincaid3 1Indiana University School Of Medicine, Department Of Surgery, Indianapolis, IN, USA 2Indiana University School Of Medicine, Department Of Medicine, Indianapolis, IN, USA 3Indiana University School Of Medicine, Department Of Neurology, Indianapolis, IN, USA 4Indiana University School Of Medicine, Department Of Radiology, Indianapolis, IN, USA 5Indiana University School Of Medicine, Department Of Obstetrics & Gynecology, Indianapolis, IN, USA
Introduction: There are numerous coding hierarchies used to communicate between healthcare providers and insurers in the United States. Current Procedural Technology (CPT) codes are the primary method to designate an interaction between a physician and a patient. Innovative or uncommon surgical procedures commonly do not have a specific CPT code to reflect the work completed. In this circumstance, nonspecific or unlisted codes are used by medical coders to reflect this interaction. Foregut and bariatric surgeons represent a surgical discipline impacted significantly by the use of unlisted codes. The goal of this study is to examine the impact of unlisted code utilization on this discipline to guide CPT hierarchy refinement.
Methods: The electronic coding and billing platform for a large academic general surgery practice was queried over a ten-year period (1/2013 to 8/2023) for use of a single CPT code, 43659 Unlisted laparoscopic procedure, stomach. A list of procedures using 43659 was generated. Collected data includes surgeon, date of service, title of procedure performed, comparison procedure name, surgeon payment, collection or denial status (5/2022 to 6/2023), and practice payment (1/2019 to 8/2023).
Results: Over a ten-year period, twenty-five “internal codes” were generated to reflect surgical procedures performed and coded with CPT code 43659. During that time, procedures coded with 43659 demonstrated a slow but continuous increase in volume. These procedures represented a small percentage of overall surgical procedures performed by the group (1% or less). However, for the surgeons who performed procedures coded with 43659, these represented an impactful percentage of procedures (as high as 8%). Surgeon payment, which is based on work relative value units (RVUs), was established by the comparison procedure reconciling the perceived effort. For the period during which payment status was available, 85% of procedures received timely payment by the insurer (127 of 150).
Conclusion: Surgeons who performed innovative and variations of mainstream surgical procedures may find that a discrete CPT code does not exist to represent that procedure. Foregut and bariatric surgeons are one group commonly impacted by this dilemma. Billing data for a large academic general surgery group queried over the last ten-years demonstrates that CPT code 43659 is used for a wide variety of surgical procedures at an increasing rate. Identifying procedures commonly billed with an unlisted code will necessitate ongoing discourse with the practice’s billing system and payors to ensure coverage and ensure access to surgical care of this type. These procedures are overwhelmingly paid by insurers.. Therefore, it behooves practices to develop a structure to ensure the surgeons who are impacted significantly by use of unlisted codes are appropriately paid for their effort.