Preparing for 2024 trends in healthcare FWA: CPT code updates and beyond

Every year, the American Medical Association (AMA) updates the Current Procedural Terminology (CPT^®) codes to reflect the latest practices, technological advancements, and regulatory requirements within healthcare. The annual updates to the CPT code set play a fundamental role in aligning coding practices with advancements in healthcare services. As healthcare continues to evolve, staying current and compliant with these updates is not just a regulatory necessity, but a means to ensure quality care delivery while minimizing fraud, waste, and abuse (FWA).

This year’s revisions encompass approximately 230 new codes, 49 deletions, and 70 revisions, representing a concerted effort to streamline coding practices and accurately reflect the evolving landscape of healthcare. As health plan special investigative units (SIUs) take on new challenges in 2024, let’s break down some of the most impactful updates as well as other trends impacting healthcare FWA.

Key areas impacted by the 2024 CPT code changes

Two key areas affected by the upcoming updates are CPT codes related to Respiratory Syncytial Virus (RSV) immunizations and evaluation and management (E&M) codes.

Respiratory Syncytial Virus (RSV) immunizations

Among the 2024 CPT code updates are the addition of five new codes related to RSV immunizations. These new codes are product-specific and designed to enhance the reporting accuracy and analysis of RSV vaccinations, aiding in data-driven planning and allocation of resources. With these RSV changes, providers may advertise early access to the vaccine in exchange for a deposit, fee, or for the patient to pay out of pocket. Some plans may not cover the vaccine, as it is not yet included on the Centers for Disease Control and Prevention (CDC) annual vaccine schedule, so members should be aware of their coverage up front. Currently, the RSV vaccine is covered under Medicare Part D and some private health plans for adults 60 years and over.

Evaluation and management (E&M) codes

Another CPT code update in 2024 affects E&M codes, involving the removal of time ranges from certain outpatient codes, such as 99202–99205 and 99212–99215. This update will also impact add-on psychotherapy codes that can be used in tandem with E&M codes. This update is being made with the intent of limiting the issue of “impossible days,” in which a provider bills for more timed services than are possible within their hours of operation. Instead, providers must meet a specific minimum time requirement for each code, aligning these codes with other E&M categories and aiming for standardization across outpatient services.

Normally, insurers see impossible days within psychotherapy but with potential upcoding of E&Ms, these time-based codes can be low-hanging fruit to investigate. If an E&M code is submitted alongside an additional psychotherapy code (such as 90833, 90836, or 90838), the clinical record must both substantiate the unique E&M service and distinctly demonstrate the provision of psychotherapy. It's crucial that providers avoid duplicating time spent on the E&M for the purposes of psychotherapy billing. The documentation needs to clearly differentiate and support each service independently.

When both are invoiced concurrently, the E&M code assumes the primary position as the parent code, while psychotherapy serves as an add-on code. The time dedicated to the E&M service cannot be used to validate the time allocated for psychotherapy since the latter relies on time-based billing as an add-on code. To support the E&M code, it's essential to provide a patient examination and demonstrate medical decision-making. These changes emphasize the need for accurate documentation of service times and potentially impact coding for outpatient visits.

Other 2024 concerns in FWA

In addition to CPT code changes, 2024 may bring an increase in FWA around testing and weight loss prescriptions.

FWA in Ozempic, Wegovy, and others

In 2023, the high prescription rate of Ozempic and Wegovy, especially within Medicare and Medicaid, raised red flags. The similarity between these drugs and potential misrepresentation of patients' conditions, leading to unverified prescriptions for weight loss rather than legitimate medical necessity, underscores the need for scrutiny in 2024.

The introduction of Zepbound, a new weight loss drug akin to Mounjaro, could lead to additional challenges for the new year. While promising increased weight loss, it necessitates strict adherence to specific criteria for prescription coverage. This stringent criteria alignment with patient diagnoses and test results is vital for insurance approval. Plans must keep an eye out for inappropriate prescription of the drug for patients who do not qualify for weight loss medication.

Amid ongoing concerns about COVID-19 that will continue in 2024, fraudulent billing for COVID-19 testing may persist. Identifying discrepancies in billing practices—such as billing for in-person testing for patients located far away, repeated testing within short intervals, or billing for tests that weren't requested nor received—will potentially continue to be vital.

Home infusion therapy

Another area of concern for 2024 is home infusion therapy, a valuable service for homebound patients requiring intravenous or subcutaneous drug administration. This past year, we witnessed an increased volume of billing irregularities in this area. Prepare for potential FWA by scrutinizing claims, evaluating provider qualifications, and assessing documentation for proper service justification to detect overbilling or insufficient services performed.

Navigating the 2024 FWA landscape

Healthcare plans, providers, and coders should prioritize education and training sessions to ensure a smooth transition to the updated CPT codes. Collaboration among coding professionals, clinicians, and administrative staff can help facilitate effective implementation and compliance with the revised codes. The continuous monitoring of reimbursement patterns and auditing for coding accuracy is crucial to identify any potential discrepancies or areas for improvement. Finally, data analysis plays a pivotal role in identifying discrepancies, validating services rendered, and flagging potentially fraudulent activities.