Use of CPT Codes to Analyze Physician Occupation

​Should CPT codes be used for billing or occupation analysis? The answer is both. 
 
In a recent lawsuit, an argument was raised that Current Procedural Terminology (CPT) codes were created and are used for billing purposes, so they should not be used in determining occupation for some reason.  One of the arguments made by an expert in the case was that charges were used, which is not a realistic measurement, as reimbursements and payments received are always less than the charge amount.  The counter argument is that charges are only one metric we use, and we recommend and use Relative Value Units (RVU) and units in all CPT analyzes.     
 
This blog will show why they can be used for both billing and the verification of a physician’s occupation.  

In all disability claims, we should consider the claim forms, representations from the insured provided in the detail call, employer statements, resumes, education, experience, the policy definition of occupation, financial documents, tax returns to determine source and amount of earnings and a CPT code analysis of the physician’s billings to help in verifying occupation.
 
Just because CPT codes were created and are used in billings does not mean that they cannot be the best way to document a physician’s occupation as well.
 
At the International Claims Association (ICA) session of “Dissecting Disability: Managing Complex Claims for Physicians, Dentists, and Attorneys, two questions from the audience proved the argument of why CPT codes should be used to analyze the duties and activities of a physician’s occupation.
 
There was a question regarding an insured that represented to be an orthopedic surgeon but performed no surgery and was entirely an office based orthopedic physician prior to claimed disability.  By analyzing the billing codes of the physician, this would easily be able to be shown. 
  
Another question was how to document the services of a physician that delivers care with telemedicine.  Again, by analyzing the billing codes of the physician, this would easily be able to be shown. 
 
So what are CPT codes and how can they be used in occupation analysis?  They are five-digits used in billing that describe the services for physicians into categories, subcategories, and description.  For a detailed understanding of each code, a book published annually by the American Medical Association (AMA) provides a detailed description with pictures and other aids. 
  
Below are the categories of CPT Codes:
 
Evaluation & Management (99201-99499)
Anesthesiology (00100-01999,99100-99140)
Surgery (10021-69990)
Radiology (70010-79999)
Pathology & Lab (80048-89356)
Medicine (90281-99199, 99500-99602)
 
In addition to the CPT code, a “modifier” can be added to the end of the CPT code to provide additional information.  This is helpful to determine when telemedicine was used, when the individual was an assistant surgeon or to distinguish between a technician and a physician rendering the patient care.  Below are some examples of “modifiers”:
 
“80” = Assistant Surgeon
“51” = Multiple Procedures
“26” = Professional Component
“TC” = Technical Component
“95” = Telemedicine

When analyzing CPT codes to verify a physician’s occupation, the following metrics related to the code should be used:
 
Units/Frequency
Charges
Relative Value Unit (RVU)
 
Most of us are familiar with units, frequency and charges, but the RVU requires an explanation.
 
Relative Value Units were created to assist in the reimbursement of physician’s charges.  The fee for each service depends on RVUs, which rank on a common scale the resources used to provide each service (Resource-Based Relative Value Scale – RBRVS).  They are updated annually by CMS (Centers for Medicare & Medicaid Services).  A higher RVU results in a higher reimbursement and a lower RVU in a lower reimbursement. RVUs, specifically work RVUs, give weight and are based on the physician’s time, technical skill, mental effort, judgement, complexity of a procedure and stress due to the potential risk to the patient.
 
Benefits of CPTs/RVUs for verifying a physician’s occupation are that the composition of services and amount of services provided by the physician can be objectively measured both pre and post disability.  This will assist in determining the physician’s occupation and the claims professional’s decision of whether the insured qualifies for total disability or residual disability under the policy. 
 
When analyzing the duties and activities of an occupation for a physician or any insured, the following factors should be considered:
 
Time
Frequency
Quantity
Money earned from duty or activity
Importance (Can you continue to earn income without the duty?)
Technical Skill/Effort
Stress due to potential risk to the patient

It is crucial to assess occupation in every claim and clear that a CPT code analysis is a best practice in the verification of physician occupation.
 
If you have any questions, please contact John Hoffman, CPA/CFF/CITP, Senior Partner, Nawrocki Smith LLP at (631) 834-2695, [email protected].