New CPT code changes for invasive cardiology and interventional radiology will take effect on January 1, 2026, impacting a significant portion of hospital net revenue and threatening to exacerbate denial rates.
Revenue cycle leaders are facing a significant new financial threat, with major CPT code changes for invasive cardiology (IC) and interventional radiology (IR) set to take effect on January 1, 2026.
These high-volume outpatient services represent an average of 12.7% of a hospital's total net revenue, according to a new quarterly benchmarking report from Kodiak.
The report warns that failing to master these complex coding changes could have a material and immediate negative impact on accounts receivable and cash flow at a time when most health systems can’t afford it.
A High-Risk, High-Denial Category
Initial claim denial rates for IC and IR outpatient claims is consistently higher than for all other outpatient claims, according to the report, and payers are particularly meticulous about reviewing these high-volume, high-value claims.
The root cause of initial denials suggests that clinical documentation is a key revenue cycle vulnerability. The report’s breakdown of denial reasons found that the top three causes for IC and IR denials were:
- Request for information (28.8%)
- Prior authorization/precertification (15.9%)
- Non-covered services (13.7%)
The data indicates that payers are determining the clinical documentation submitted is either missing or insufficient to support the codes being billed.
Why the Code Changes Create a New Threat
While initial denial rates for IC/IR claims are high, providers are often successful at appealing them. The final denial rate for IC and IR claims is just 0.5%, significantly lower than the 3.3% average for all outpatient claims. This indicates that revenue cycle teams are effective at overturning initial denials through appeals.
However, the report warns that this success is in jeopardy.
New rules include at least 84 coding changes, including 48 new CPT codes and 24 eliminated codes. These changes could make an already challenging initial claim denial environment worse and exacerbate existing issues with documentation-related denials, according to the report.
The primary concern is that providers may not be able to sustain their current appeal success rate. Payers may use the new codes as leverage to deny claims, according to the report.
An Action Plan for Revenue Cycle Leaders
Revenue cycle leaders should act now to mitigate the potential impact. Steps they can take include:
- Educating Clinicians: Train physicians, nurses, and technologists on the new clinical documentation required to support the 48 new CPT codes.
- Training Coders: Ensure coders are prepared for the 84 coding changes to maintain accuracy and prevent an immediate spike in denials.
- Updating Payer Protocols: Revenue cycle teams must update their prior authorization and precertification protocols to reflect the new codes and payer requirements.
- Updating Technology: Health IT teams must update EHR, billing, and claims management systems to map the new codes to the appropriate services and documentation.
- Monitoring KPIs: Leaders must closely monitor initial and final denial rates, as well as RFI denial rates, specifically for IC and IR services, to immediately track the impact of the changes.
Luke Gale is the revenue cycle editor for HealthLeaders.
KEY TAKEAWAYS
Invasive cardiology (IC) and interventional radiology (IR) services account for an average of 12.7% of a hospital's total net revenue.
IC and IR claims already face a higher initial denial rate than other outpatient claims, suggesting a high risk for documentation-related denials.
While providers are currently successful at appealing these denials (a 0.5% final denial rate), the 84 new coding changes will require significant training for clinicians and coders to prevent a new surge in final denials.