CurrentMolina HealthcarePolicy N/A

CPT coding and reimbursement audit policy

Governs Molina Healthcare's review, auditing, and recovery processes for CPT coding and billing accuracy for providers; affects Molina-contracted providers and applies according to state and federal requirements.

Policy Summary

PayerMolina Healthcare

PolicyCPT coding and reimbursement audit policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMolina may conduct CPT-to-CPT code reviews and will notify providers of discrepancies, allowing them the opportunity to respond or correct errors.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

audits may be initiatedtriggers for review

fund recovery permittedoverpayment recovery

09/08/2023created

08/20/2025last revised

Reimbursement and Audit Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ANY of the following

Billing outliers (unusual payment or utilization patterns)
High or excessive frequency of services
Member or provider complaints regarding coding or billing
Unusual billing practices

ALL of the following

Conduct CPT-to-CPT code reviews to ensure claims are billed appropriately and services meet medical necessity requirements
Examine medical records, billing records, and other relevant documentation to support coding and billing decisions
Focus review on issues including mutually exclusive codes, bundling/unbundling errors, incorrect use of add-on or replacement codes, global surgery code errors, and improper multiple procedure or surgery discounts

ALL of the following

Notify the provider when discrepancies are identified and allow the provider an opportunity to respond or correct errors
Allow providers to submit supporting documentation or corrections as part of the audit process

ALL of the following

Recover overpayments in accordance with federal, state, and contractual requirements
Pursue claim denial, rejection, or other corrective measures, including recovery of claim payments as allowed by applicable law and contract terms

ALL of the following

Federal and state guidelines, the member's benefit plan document, and provider contract language supersede this policy in case of conflict
Codes listed in the policy are for reference only; listing does not guarantee coverage and coverage is determined by the benefit document; providers must adhere to current CPT coding guidelines and industry standards

Audit focus operational note:

Audits will follow the most current coding guidelines and industry standards; Molina reserves the right to revise the policy and to reject/deny claims or recover payments when improper billing is identified.

CPT Guidance and Audit Triggers

CPT guidance and disclaimerCPT

CPT codes referenced for coding guidance; listing is informational and not a guarantee of coverage.

Audit triggers

Audit triggersHigh frequency of services; billing outliers/unusual billing practices; member or provider complaints

What auditors reviewMedical records, billing records, and other relevant documentation to determine coding appropriateness

Potential audit outcomesProvider notification with opportunity to respond/correct; possible fund recovery if inaccurate billing confirmed

Audit Process and Provider Notification

Prior Authorization

Audit and Provider Notification — Opportunity to Respond

Molina Healthcare may perform CPT-to-CPT code reviews to verify claims are billed appropriately and meet medical necessity; if discrepancies are found, Molina will notify the provider and allow an opportunity to respond or correct the error.

Molina may conduct CPT-to-CPT code reviews to ensure claims are billed appropriately and services meet medical necessity requirements.
When discrepancies are identified, Molina will notify providers and allow them the opportunity to respond or correct errors.

Terminology and Code Concepts

Mutually Exclusive Codes

DefinitionCodes that cannot be billed together for a single patient on a single date of service because they represent overlapping services

Audit relevanceMutually exclusive pairings are a primary focus during CPT-to-CPT code reviews to identify improper billing

Action when identifiedProvider notified and allowed to respond; overpayment recovery may follow if inappropriate billing is confirmed

Bundling/Unbundling

DefinitionThe practice of consolidating multiple related procedures into a single billing code or separating a single procedure into multiple billing codes

Audit relevanceBundling/unbundling errors are specifically listed as a focus area during audits of same-day or related services

Provider expectationProviders must follow current CPT guidelines to justify separate or bundled billing

Add-On Codes

DefinitionCodes that represent additional services performed in conjunction with a primary procedure

Audit relevanceIncorrect use of add-on codes is a flagged issue during CPT reviews and may lead to adjustments or recovery

Billing implicationAdd-on codes should only be billed when the additional service meets CPT criteria and is supported by documentation

Replacement Codes

DefinitionNew codes that replace old codes for more accurate billing and reporting

Audit relevanceReplacement code usage is reviewed to ensure providers use current, accurate CPT codes

Provider obligationProviders should adhere to the latest CPT coding guidelines to avoid miscoding with outdated codes

Global Surgery Codes

DefinitionCodes that include the surgical procedure and the pre-operative and post-operative care

Audit relevanceGlobal surgery code errors are specifically identified as an audit focus when multiple services occur around surgery

Billing implicationServices included in the global period should not be billed separately unless CPT guidance allows

Multiple Procedure Discounts

DefinitionReductions in reimbursement for additional procedures performed during the same session

Audit relevanceImproper application of multiple procedure or surgery discounts is reviewed during audits of same-day services

Payment impactAdditional procedures may be reimbursed at a discounted rate per CPT or payer policy when performed in the same operative session

CMS

DefinitionThe Centers for Medicare & Medicaid Services

Role in policyCMS guidance and coding rules are referenced as foundational resources for Molina's coding and audit processes

Governing hierarchyFederal/state guidelines, including CMS, supersede this policy when conflicts exist

Policy Summary

PayerMolina Healthcare

PolicyCPT coding and reimbursement audit policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMolina may conduct CPT-to-CPT code reviews and will notify providers of discrepancies, allowing them the opportunity to respond or correct errors.

SourceLink

On This Page