Implications of Current Procedural Terminology code accuracy on surgical workflow and financial reimbursement

Malcolm Su, Laura D. Leonard, David Marchant, Jeniann Yi, Ethan Cumbler, Robert Meguid, Jean S. Kutner, Kathryn Colborn, Brent Rikhoff, Sarah Tevis


Objective: Inaccuracies in Current Procedural Terminology (CPT) coding entries for surgical procedures have a profound impact on hospital systems and surgeon compensation for services. We sought to characterize the variations of surgical CPT entry at a multi-site academic medical center and estimate the financial burden implicated by improper code entry.
Methods: A mixed methods study was conducted to evaluate variations in CPT entry across an academic center. Semi-structured interviews with 8 surgical schedulers were conducted and analyzed to understand the current scheduling process. Coding data for surgical procedures performed within a 31-day period during September and October 2020 within the large healthcare system were assessed for appropriate CPT code entry. Reimbursement for the 2020 fiscal year was then analyzed to determine the impact of pre-operative CPT code accuracy on reimbursements and denials.
Results: Interviews revealed a lack of standardization in the surgical scheduling process across the hospital system. Lack of standardized onboarding and variations in workflow contributed to difficult cross coverage for schedulers and errors in CPT entry. On quantitative analysis, the accuracy of pre-operative CPT code entry was poor with only 59.3% of pre-operative CPT code entries being correct. In the 2020 fiscal year, $5.4 million was lost due to problems related to CPT code entry.
Conclusions: Variations and lack of standardization in CPT code entry can greatly contribute to financial losses and disrupt surgical scheduling. Standardization of workflow and CPT entry schemes can help minimize scheduling complications and enhance the quality of care provided to patients.

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Journal of Hospital Administration

ISSN 1927-6990(Print)   ISSN 1927-7008(Online)

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