Abstract

First developed in the 1960s by the American Medical Association, the Current Procedural Terminology (CPT®) standardized coding system sought to simplify recording medical services and procedures in the United States.  As the preferred coding system by both federal and private payers, health professionals are required to be proficient in the CPT® system if they expect compensation. Given the complexity of the ever changing CPT® system with many codes being added and changed every year, many health systems have started to utilize in-house professionals or have outsourced their billing and coding responsibilities to third parties. Here we present the findings of an internal audit of a single code category for case consultations in an academic organization outsourcing its billing. In the last 2 years, we noted 78 consultations inaccurately coded at 88321 (microslide consultation) instead of 88325 (comprehensive review of data), despite appropriate documentation of medical record review required for the case. Potential revenue not captured by the healthcare system is estimated at $4,419, with 67.86 relative value units (RVU) unclaimed by the pathologist. A single category audit can be helpful in determining the accuracy of an organization’s current billing practices. Steps for more comprehensive routine self monitoring has included monthly review of coding statements for inaccuracies of unexpected coding outliers.