Audit Cases

New Codes, Guidelines, Medical Billing Considerations in 2025

The complexities surrounding medical coding, billing and submitting an accurate claim the first time is a given. Anyone in the business of healthcare will attest that keeping up with CPT, HCPCS and ICD-10 code revisions and updates, variations of health plans guidelines and policy instructions, numerous Medicare laws, regulations, and other related healthcare matters give rise to ongoing challenges and opportunities to the revenue cycle process. It also shines a spotlight on ensuring healthcare providers and suppliers are compliant with their coding, billing and submission of medical claims, have supporting documentation for reported and billed procedures, and receive proper reimbursement.  

To initiate the claims filing process, it is necessary to obtain member information, demographics, insurance information and other data. Another layer involves capturing all services provided, applying associated charges and determining who provided the service — practitioner, hospital, ambulatory surgical center, diagnostic imaging center, DMEPOS supplier, home health agency or a host of other provider types.  

There must be a solid team of players to complete the required claim field elements for the submission of the claim to health plans. Healthcare claim information is all about the numbers. A brief overview below demonstrates the thousands of codes, billing considerations and necessary information needed to bill health insurance claims.  

CPT 2025 Changes 

The American Medical Association released the CPT 2025 code set with 420 code updates to the CPT code book. These changes are effective Jan. 1, 2025, and includes the following: 

  • 270 new codes 
  • 112 code deletions 
  • 38 code revisions 

There are more than 11,000 CPT codes that serve as the standardized terminology for communicating the use of medical, surgical and diagnostic services across healthcare. CPT codes are also utilized for study, tracking and reimbursement. 

Some key CPT changes include the ongoing expansion of proprietary laboratory analysis tests, chiefly for novel genetic testing, and Category III CPT codes for emerging medical services. 

Other changes include new codes for reporting digital medicine services, augmented and artificial intelligence involving ECG measurements, medical chest imaging and image-guided prostate biopsy, and CPT’s general surgery section.  

Other Code Sets and Numbers

  • HCPCS codes: over 8,000 codes  
  • ICD-10-PCS codes: over 87,000 procedure codes 
  • ICD-10-CM codes: over 70,000 codes  

Additional Numbers

  • Modifiers: over 250 
  • Revenue codes: over 175 
  • Place of service codes: over 50 
  • MS-DRG codes: over 740  
  • Date(s) of service 
  • Quantity units of service 
  • Bill types 
  • Charges 
  • Other data 

Claim Forms Used to Submit Healthcare Services 

Form CMS-1500 (paper) — Electronic Equivalent 837P 

  • Used to report and bill services provided by physicians, other qualified healthcare professionals and suppliers 
  • Contains 53 form locater fields 

Form CMS-1450 or UB-04 (paper) — Electronic Equivalent 837I 

  • Used to report and bill services provided by hospitals (inpatient and outpatient care), skilled nursing facilities, rehabilitation facilities, home health agencies, ambulatory surgical centers and others 
  • Contains 81 form locator fields 

Common Errors Identified in Medical Coding, Billing 

In addition to getting all the selected numbers and data entry information accurate on the claim, considerations of multiple coding and billing guidelines must be applied. Some common coding errors include: 

  • Unbundled codes — Unbundling refers to using multiple CPT/HCPCS codes for the individual parts of the procedure, either due to misunderstanding or to increase payment. When there is a single code available that captures payment for the component parts of a procedure, that is the applicable code to report/bill. Another example is the unbundling of routine hospital items/supplies which are considered part and partial to other reported and billed hospital services. 
  • Upcoding — Examples include routinely reporting the highest-level of evaluation-and-management service code regardless of the actual condition the patient presents with. Always billing the highest-level of E/M code due to being a “specialty practitioner” or billing for 30- or 60-minute face-to-face E/M visits when that amount of time is not spent with the patient and supported by medical record documentation. Coding for an excision of a 2.5-cm skin lesion (11403) when documentation supports lesion was 1 cm in diameter (11401). 
  • National Correct Coding Initiative edits — The Centers for Medicare and Medicaid Services developed NCCI edits to help ensure correct coding methods are followed to help avoid improper payments. These are automated prepayment edits that are reached by analyzing every pair of codes billed for the same patient on the same service date by the same provider to see if an edit exists in the NCCI. In some circumstances, it is appropriate to utilize a modifier to override the edit denial and in other cases, the guideline is clear that no modifier may be used to override the edit denial. 
  • Failure to report appropriate modifiers or misuse of modifiers — Some codes by definition are a bilateral procedure and as such, modifier 50, bilateral procedure is not necessary to add to the reported procedure code since it is already defined as a bilateral service. Not using a required modifier with specific codes or scenarios is considered a billing error and can result in nonpayment of the service code.
  • Improper reporting of codes defined by time, improper reporting of anesthesia time or improper reporting of ambulance miles — Lack of documentation to support the actual time spent providing the services, time spent providing anesthesia services or ambulance milage reported and billed on the claims. 

ClaimDOC’s Auditing and Pricing of Claims 

ClaimDOC’s approach to claims analyses is unique as processes are built for specific auditing and advocacy. Talented, certified healthcare professionals perform a comprehensive line-by-line claim review to uncover errors typically not caught by claim scrubbers and automation. Our audit team’s unique combination of various healthcare backgrounds, diverse skills, clinical expertise and variety of perspectives result in critical thinking skills that automation cannot accomplish when coding and billing data reported on claims appears questionable. A commonsense approach is used to identify codes and services integral to other billed items and services; incorrect reporting of outdated CPT, HCPCS, ICD-10-CM codes; misuse or lack of modifier usage; inaccurate information on the claim; duplication of services; and other areas of concern. 

We have uncovered numerous errors of improper reporting of quantity units, unbundling of services, misuse of modifiers, incorrect use of add-on codes, improper assignment of diagnosis codes, invalid diagnoses on claims, outdated codes, incorrect bill type, improper billing of professional services on hospital claims, and the list goes on. Our primary goal is to fairly price all services timely and accurately. Coverage and benefit determinations are left to the third-party administrator. 

Summary 

The new AMA CPT codes, Medicare HCPCS codes, billing guidelines and Medicare updates effective Jan. 1, 2025, impact billing and coding of claims across all medical specialties. Staying informed about the latest changes and updates is essential. Review the official AMA code updates, Medicare HCPCS codes, update coding resources and tools, participate in training, and communicate information with all applicable staff to help ensure a smooth transition to minimize billing errors and rework of claim submissions.  

There must be ongoing coordination, discussion and education to help ensure accurate claim submission. Refiling and re-billing claims due to billing and coding errors is inefficient and increases administrative expenses for all parties involved.  

At the end of the day, accurate coding and billing by healthcare providers assists with the proper reimbursement and payment for provided services, helps ensure quality compliance and minimizes the risks of potential overpayments, fines and penalties. Revenue integrity and payment integrity should be viewed as complimentary processes, bridging the divide. Providers and payors both benefit through shared goals and collaboration. Claims can be processed promptly and correctly, and providers can be paid appropriately and timely, creating a win-win.