Philadelphia Reflections

Collapsing the Codes

Problem:CPT, with 900 codes, is the most detailed of the several popular systems for symbolizing clinical activities. Even so, many of the codes are imprecise and could easily be broken down into components. There is moreover little doubt the coding system will need to be steadily expanded in the future to accommodate changes in practice. On the other hand, health insurance third parties have great difficulty coping with changing definitions of what they must pay for, a difficulty made more severe by cost containment pressures. Pennsylvania Blue Shield, for instance, recently found itself mandated to change from a modified CPT-2 system with 4500 codes to CPT-4, with 9000. Since the prevailing fee system is based on historical profiles, there was a strong incentive to collapse 9000 codes back toward the original 4500 through computer algorithms (program instructions) which essentially treated two new codes like one old one. Sometimes, the new system had fewer gradations of a procedure than the old one, and this problem was resolved by eliminating one or more of the old gradations; when the gradation eliminated was the most highly paid of several physician complaints have been accusatory.

we thus have a physician community protesting that codes are being collapsed to their disadvantage, without their knowledge or consent. We also have an insurance community which is paranoid about the motives of a medical profession which appears to be endlessly exploding the codes. Each group is able to provide illustrations of bad faith behavior by the other, but in fact, both groups need to work together to reduce inevitable friction at the interface.

Proposal: That a joint project be undertaken to specify the rules for making A + B = C, with the understanding that when A+B is agreed to be equivalent under either form of presentation on claims forms. Further, that a mini form of Relative value scale be created, limited to and unique to gradations within a single procedural category, wherever experience shows there are legitimate disputes about using the value of a single payment. Finally, for that large group of instances in which conducting the project activities in an advisory capacity producing public opinions, and if necessary, minority opinions for the guidance of local negotiations.

Originally published: Thursday, August 23, 2018; most-recently modified: Wednesday, May 15, 2019