Here's why a proposal for prior authorization CPT codes returned to the drawing board

A recent proposal to report prior authorization to insurance plans through CPT codes was withdrawn at the eleventh hour when its physician advocate made an unexpected discovery: For certain codes and in very narrow circumstances, the prior auth requirements were already in place.

Alex Shteynshlyuger, M.D., director of urology with New York Urology Specialists, had previously brought forward a time-based proposal that would ensure physicians are compensated for time spent on prior auth claims. He believed the changes would also reduce the number of claim requirements imposed by plans and limit the amount of appeals and could lead to better patient outcomes.

Following the proposal, however, the American Medical Association (AMA) informed Shteynshlyuger that prior authorization is already explicitly mentioned in official procedure descriptions for half a dozen CPT codes. This required Shteynshlyuger to withdraw the proposal so he could revise and resubmit at a later date.

Each CPT code includes a short description detailing the type of visit or examination. Longer descriptions—where the prior auth mentions were contained—are also stored in databases that can be purchased, but those are rarely encountered.

“As a matter of fact, I’ve never seen the long description in my lifetime,” said Shteynshlyuger.

Each year, the AMA publishes a CPT Changes book describing the past year’s recent changes. The organization also sells an online data manager, and providers may partner with companies like Optum that are updated with recent changes. But most physicians do not know how to access these descriptions or would not think to look for prior auth information there.

The six CPT codes and their accompanying long descriptions were shared with Fierce Healthcare. The AMA gave permission to Shteynshlyuger to distribute them to the media. Prior authorization is not alluded to in the short descriptions, unlike its mention in the longer descriptions.

“It turns out that a few years ago, the AMA CPT panel revised the long description of the CPT codes and surreptitiously added prior authorization to it,” he said. “I’m not really sure why they have not made physicians aware.”

Under these CPT codes, billing for prior auth only applies in certain scenarios. In these scenarios, the codes only address same-day evaluation management visits and time spent by a physician completing the claims. Billing completed by prior auth specialists or medical assistants do not count.

If these requirements are met, all health plans must follow the guidance.

Shteynshlyuger intends to resubmit his proposal with “dedicated codes” once it is ready because there are many situations where the CPT codes cannot be used to reimburse physicians. Additionally, CPT codes allow the effects of prior auth to be better studied, improving healthcare delivery in the long run.

In 2021, the AMA revamped the codes and guidelines for outpatient evaluation and management services in its CPT handbook.

“The AMA is helping physicians and healthcare organizations prepare now for the transition and offers authoritative resources to anticipate the operational, infrastructural and administrative workflow adjustments that will result from the pending transition,” said the AMA president at the time, Susan Bailey, M.D., in a news release.

AMA members also have access to a CPT Assistant, helping provide resources to members with coding and billing questions. It helps clinicians appeal insurance denials and assists with other day-to-day questions.

The organization told Fierce Healthcare it will soon publish a new article on its website to help physicians and coders better understand evaluation and management office visit codes in reporting work associated with prior auth requirements using the CPT Assistant.