If a CPT code is routinely denied by a third-party payer, what type of review should the specialist perform?

In situations where a CPT code is frequently denied by a third-party payer, conducting a retrospective review is the most appropriate course of action. This type of review allows the billing and coding specialist to analyze previously submitted claims and their outcomes over a specific period. By reviewing past denials, the specialist can identify patterns or common reasons for the denials related to that specific CPT code.

A retrospective review involves assessing the documentation, coding accuracy, and compliance with payer guidelines. This can uncover potential issues such as incorrect coding, lack of medical necessity, or failure to meet the criteria set by the insurance provider. By understanding the reasons behind past denials, the specialist can make necessary adjustments and improve future claims submissions, thereby reducing the likelihood of repeated denials and enhancing reimbursement rates.

Utilization review, on the other hand, generally focuses on the appropriateness of medical services and ensure they align with healthcare regulations and criteria, rather than specifically addressing coding denials. Prospective and concurrent reviews typically assess services before they occur or during treatment, which does not apply to a situation involving frequent denials of a previously submitted CPT code.