CPT Process for Code Creation

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CPT Process for Code Creation

Business of Medicine
Author Credentials 

Richard Waguespack, MD
Professor of Otolaryngology
Department of Otolaryngology-Head & Neck Surgery
University of Alabama-Birmingham
Birmingham, AL

Lawrence M. Simon, MD
Clinical Assistant Professor of Otolaryngology
Department of Otolaryngology-Head & Neck Surgery
LSU Health Sciences Center
New Orleans, LA

Module Learning Objectives 
  1. Review CPT process in detail.
  2. Explain the role of the AMA RUC (Resource Based Relative Value Scale Update Committee (RUC).
  3. Define the role of organized medicine in creation and maintenance of the CPT Code set.
What does CPT Stand For?
  1. Current Procedural Terminology.
  2. Codes are not specialty-specific and may be reported by any qualified healthcare provider, typically defined by the jurisdiction in which one is licensed and the regulatory framework in which one practices.
  3. CPT is defined by statue [Administrative Simplification Section of the Health Insurance Portability and Accountability Act (HIPAA) of 1996] as a reporting methodology for physician/healthcare services.
CPT Editorial Panel
  1. Role
    1. AMA committee that develops and maintains the CPT Code set
    2. There are no designated specialty positions and its serving members do not represent their specialty while on the Panel; efforts are made to broadly represent medicine broadly defined
    3. Established by the AMA in 1966, no taxpayer money has been used to develop and maintain CPT
    4. 3 meetings are held per year during which CPT code applications are presented to the Panel; outcomes may be approval, denial, or postponement to a future time
  2. Membership, quoting from the AMA CPT website:
    • "The CPT® Editorial Panel is responsible for maintaining the CPT code set. The panel is authorized by the AMA Board of Trustees to revise, update, or modify CPT codes, descriptors, rules and guidelines. The panel is composed of 17 members. Of these, 11 are physicians nominated by the national medical specialty societies and approved by the AMA Board of Trustees. One of the 11 is reserved for expertise in performance measurement. One physician is nominated from each of the following:
      • Blue Cross and Blue Shield Association
      • America's Health Insurance Plans
      • American Hospital Association
      • CMS
    • The remaining 2 seats on the CPT Editorial Panel are reserved for members of the CPT Health Care Professionals Advisory Committee (HCPAC). Five members of the editorial panel serve as the panel's executive committee. The executive committee includes the editorial panel chairman, co-chairman and 3 panel members-at-large, as elected by the entire panel. One of the 3 members-at-large of the executive committee must be a third-party payer representative."
  3. CPT Advisory CMTE
    1. CPT Advisor and Alternate may be nominated by national specialty societies and approved by the AMA; see below.
    2. These advisors present to the Panel and give specialty expertise to the Panel, CPT Assistant, and provide correct coding advice on an ongoing basis
  4. CPT Assistant
    1. This is a monthly publication that contains articles on correct CPT coding, with examples, FAQs, and illustrative cases 
    2. The publication is overseen by the CPT Assistant Editorial Board, whose chair is the vice-chair of the Editorial Panel and members include physician and non-physician coding experts
  5. Relationship to valuation and payer policy 
    1. RUC (AMA Relative value scale Update CMTE) determines valuation of Category I CPT Codes. See below and related module on the RUC.  
    2. Payer policies
      1. Vary amongst payers (set fee schedule, relation to Medicare, which codes are covered)
      2. Payment generally requires a service be 1-medically necessary and 2-non-investigational/non-experimental (as defined by the plan)
    3. The presence of a Category I code does not guarantee that all payers will cover the code
Steps in the CPT Cycle
  1. Who can propose CPT Code additions, changes, deletions?
    1. Individuals, specialty societies, industry, other Interested Parties, Payers
    2. Staff
    3. RUC screens (eg, site of service anomalies, reporting multiple codes together frequently) 
    4. Codes sent to the RUC may be returned to the CPT Editorial Panel for refinement for issues relating to the valuation process (eg, need to define codes for a pediatric and an adult population)
  2. Types and Components of CPT Codes
    1. Category I which are standard, frequently used codes which require clinical and literature support and widespread use; requirements are as follows from the AMA CPT website:
      1. All devices and drugs necessary for performance of the procedure of service have received FDA clearance or approval when such is required for performance of the procedure or service.
      2. The procedure or service is performed by many physicians or other qualified health care professionals across the United States.
      3. The procedure or service is performed with frequency consistent with the intended clinical use (i.e., a service for a common condition should have high volume).
      4. The procedure or service is consistent with current medical practice.
      5. The clinical efficacy of the procedure or service is documented in literature that meets the requirements set forth in the CPT code-change application.
    2. Category II Performance Measurements Codes
    3. Category III are commonly referred to tracking, new technology, or “T” codes; requirements are as follows from the AMA CPT website: The procedure or service is currently or recently performed in humans AND At least one of the following additional criteria has been met:
      1. The application is supported by at least 1 CPT or HCPAC Advisor representing practitioners who would use this procedure or service (or)
      2. The actual or potential clinical efficacy of the specific procedure or service is supported by peer reviewed literature which is available in English for examination by the CPT Editorial Panel (or)
      3. At least 1 Institutional Review Board approved protocol of a study of the procedure or service being performed
      4. A description of a current and ongoing United States trial outlining the efficacy of the procedure or service or
      5. Other evidence of evolving clinical utilization
    4. Introductory Language
      1. Many sections in the CPT codebook have introductory language that defines the services and gives guidance for their correct usage. This language applies to the codes in that section.
    5. Modifiers
      1. CPT defines a number of modifiers which are appended to a code to define there is something different or unusual about its use; modifiers do not fundamentally change the definition of a CPT code. 
      2. An example is modifier 24, which is used with an Evaluation and Management service (E/M) performed during a surgical global period to indicate that the E/M service is being performed for a diagnosis unrelated to the global period surgery.  (eg, E/M for an unrelated otitis media during the 90-day global period of tonsillectomy) 
    6. Parentheticals and inter-relationships between codes
      1. Many codes have parentheticals listing the circumstances for which they can or cannot be used, such as with other services or CPT codes
    7. Unlisted codes
      1. Virtually all sections include an unlisted code (often ending in -99) allowing reporting of a service not listed by an existing CPT code. CPT is meant to be granular in the sense that if a service is performed for which a defined CPT code (or codes, Category I or III) does not exist, the service is typically reported with the appropriate unlisted code. 
    8. Bundling and code edit software
      1. Understand the definition of bundling
      2. “Code edit” refers to code pairings that are considered bundled, and therefore are typically not paid separately
      3. National Correct Coding Initiative (NCCI) is the initiative used by Medicare to determine how codes may be reported together. It is also used by many other payers that utilize the Medicare System (RBRVS) for reimbursement. There is quarterly review involvement of proposed edits by the Academy. 
      4. Other private companies (e.g. McKesson) also publish edits that other payers may use.
    9. Code “families.”
      1. Defined by initial words of the code, semicolons, and indentations in the code book.
      2. When a code is revalued, all codes in the family are re-valued.
      3. The total value of the code family must remain budget neutal
  3. Role of Specialty Societies
    1. Specialties have CPT Editorial Panel representation with a CPT Advisor and Alternate.  Any society with AMA House of Delegates representation may have an Advisor and Alternate Advisor. Otolaryngology has representation from the following societies: AAO-HNS, Triological Society, AAFPRS, AAOA
      1. A specialty may “own” specific codes (eg, AAO/HNS “owns” endoscopic sinus surgery and otologic surgical codes like tympanoplasty). In these cases, that society works with its committee structure and subspecialty societies to modify CPT to best serve the specialty
      2. Many societies have a senior Health Policy Advisory Committee.  For AAO/HNS, this committee is called the Physician Payment Policy Workgroup (“3P”).  3P is the senior health policy group within the AAO/HNS and reports to the Board of Directors. It consists of senior volunteer physicians, many of whom represent the specialty to the CPT Panel and RUC as well as dedicated Academy staff. 
      3. Most societies, such as the AAO/HNS have a rigorous process for assessing new technology in the context of the CPT process (eg, the New Technology Pathway of AAO/HNS). These processes help ensure that CPT code development in relation to new technologies is carried out in alignment with core CPT principles.
    2. Inter-specialty considerations
      1. When a society’s work overlaps with other specialties (eg, skull base with neurosurgery, thyroid and parathyroid surgery with general surgery) CPT changes must be presented in coordination with other users, typically their specialty society advisors and staff
Additional Information
  1. https://www.entnet.org/content/reimbursement
  2. Ahlman J. T., Attale T., Bell J., et al: Current Procedural Terminology (CPT®) 2018 Professional Edition. American Medical Association. American Medical Association; Spi Pro edition, September 1, 2017.
  3. CPT® (Current Procedural Terminology)
Resources 

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  1. Annual Meeting Webcast (AMW):

ACS Resouces