Health Insurance Exchange Problems Hit Patients, Practices Hard

By P.j. Cloud-moulds from Physicians Practice

Wow, what a week!  What a year, I should say.  The state of California has seen many, many changes since January 1. How these changes are affecting physicians and practices is mind-boggling.

Here are a few of the biggest changes practices are experiencing: 1. A new California law allows patients to walk into a physical therapy office without a prior prescription and receive treatment for a specific number of visits or days.  The problem is that some insurance companies still require a prescription from a licensed physician.  Unfortunately, insurance companies often don't share this information at the verification level with the physical therapist, and the claim is denied or delayed in payment.  This has been a treat to figure out, but most of the patients have primary-care physicians that the physical therapist can fax the evaluation to, and this seems to satisfy the insurance companies need for a prescription. 2. The next change relates to the California workers compensation fee schedule.  It transitioned from very specific 30-minute timed codes to the Medicare Fee Schedule.  The problem is that very few of the workers compensation plans actually implemented this change and they are pulling the, “We didn't know” card.  Senate leaders in Sacramento have filed complaints against many of these plans. Liberty Mutual, your time to pay up has come!  I strongly advise practices to review their workers compensation claims with their healthcare and billing staff to make sure they are using the updated fee schedule, that the workers compensation plans are paying per the fee schedule, and that someone is following up with these types of claims. 3. Our latest fiasco has been my favorite so far:  Covered California. It really should be called Uncovered California.  This blog article is certainly not long enough to list all of the fiascos that we uncovered this week, but let me name a few.  Blue Shield created a “narrowed network" and many physicians that participate with Blue Shield are not in network on the new exchange plans. That means that if a patient purchases a Blue Shield exchange plan and calls for an appointment and a practice's front-office staff mistakenly believes it is in network, the patient may have to pay out-of-network rates around a 50 percent coinsurance for receiving services at your practice.   I have identified a common group number of X001004 and alpha prefixes of XEA, XEC, XED, XEK followed by 900.  These two are tip-offs that the patient is on exchange, off exchange, or underwritten.  All of these scenarios claims are processing out of network.Some of the health cards have the “Covered California” logo on them, some don't.  All of the plans indicate that they are some sort of PPO, so practices usually don't think twice about not being in network.  Patients are angry and up in arms about all of this.  While trying to figure this all out, I came across the Blue Shield Facebook page. If you want a laugh, take a look.  The company's canned responses are similar to the recorded messages and disclaimers you get when you call.  Blue Cross of California also has several new plans in which many providers are considered out of network.  Practices in the state of California may want to spend a few hours to identify patients with the alpha prefix JQD, JQM, JQN and VXB with corresponding group numbers of 0RX, 0RY (zero not “O”).  It is imperative that practices discuss these out-of-network issues with their staff so that they are aware when patients call and start yelling about getting their bills.

Article From Physicians Practice  http://www.physicianspractice.com/blog/health-insurance-exchange-problems-hit-patients-practices-hard?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=18022014

Ethics on Ending the Patient-Physician Relationship

Once you accept a patient into your practice, you are under an ethical and legal obligation to provide services to the patient as long as the patient needs them.  There may be times, however, when you may no longer be able to provide care.  It may be that the patient is noncompliant, unreasonably demanding, threatening to you and/or your staff, or otherwise contributing to a breakdown in the patient-physician relationship. Regardless of the situation, you must avoid a claim of "patient abandonment."  Abandonment is a tort, similar to negligence, defined as the termination of a professional relationship between physician and patient at an unreasonable time and without giving the patient the chance to find an equally qualified replacement.
There must be some harm from the abandonment.  The plaintiff must prove that the physician ended the relationship at a critical stage of the patient's treatment without good reason or sufficient notice to allow the patient to find another physician, and the patient was injured as a result.  Usually, expert evidence is required to establish whether termination happened at a critical stage of treatment.
A physician who does not terminate the patient-physician relationship properly may also run afoul of ethical requirements, and find himself before the medical board.  According to the AMA's Council on Ethical and Judicial Affairs, a physician may not discontinue treatment of a patient as long as further treatment is medically indicated, without giving the patient reasonable notice and sufficient opportunity to make alternative arrangements for care.  Further, the patient's failure to pay a bill does not end the relationship, as the relationship is based on a fiduciary rather than a financial responsibility.

According to the AMA's Code of Medical Ethics, Opinion 8.115, you have the option of terminating the patient-physician relationship, but you must give sufficient notice of withdrawal to the patient, relatives, or responsible friends and guardians to allow another physician to be secured.

The Health Care District of Palm Beach County offers this advice regarding the appropriate steps to terminate the patient-physician relationship:

1. Giving the patient written notice, preferably by certified mail, return receipt requested;
2. Providing the patient with a brief explanation for terminating the relationship (this should be a valid reason, for instance non-compliance or failure to keep appointments);
3. Agreeing to continue to provide treatment and access to services for a reasonable period of time, such as 30 days, to allow a patient to secure care from another person (a physician may want to extend the period for emergency services);
4. Providing resources and/or recommendations to help a patient locate another physician of like specialty; and
5. Offering to transfer records to a newly-designated physician upon signed patient authorization to do so.

Following this protocol may be easier in some situations than others.  For example, if a physician has signed a covenant-not-to-compete, chances are the employer will not hand over the patient list upon notice of departure.  In instances such as these, you (in consultation with your attorney) may want to provide a model patient termination letter to the party withholding your patients' addresses, and request that the addresses and letter be merged for distribution to your patients. 
Ideally, you should not be in a contractual arrangement that makes contacting your patients difficult.  However, if you find yourself in this situation, work with an attorney to ensure that appropriate steps are taken.

Article  By Martin Merritt of Physicians Practice http://www.physicianspractice.com/blog/ethics-ending-patient-physician-relationship?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=29102013

Complaints and Disputes Against Insurers

When an insurer or payer denies a claim unfairly or otherwise conducts business in an inappropriate manner, a physician practice can and should take action. Use the information on this page to better understand and navigate the complaint process.

Complaint proceduresPhysicians should first try to resolve the issue through the third-party payer’s internal complaint submission process. If you feel that your issue was not properly addressed in the internal process, consider seeking an impartial review by a state insurance regulatory agency, your state medical association or the AMA. Understand what to expect during the complaint process.

Filing a complaint against an insurer – mapTo assist you with the process of filing a complaint with the AMA, your state medical association or state insurance regulatory agency, the AMA has compiled the complaint process procedures for every state. Information is available through an easy-to-use interactive map.

Health plan complaint formUse the AMA Health Plan Complaint Form to let the AMA know about the hassles and unfair business practices you experience in your day-to-day interactions with health insurers.

File a HIPAA-related complaint
Physicians are encouraged to file a complaint with the AMA when an insurer is out of compliance with Health Insurance Portability and Accountability Act (HIPAA) transaction and code set standards. Also learn how to file a complaint with the Centers for Medicare and Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS).

Courtesy of : AMA http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/health-insurer-payer-relations/complaints-disputes.page?

Overpayment Recovery

Physician practices frequently have to deal with allegations that they have received overpayments from commercial and governmental payers. Attempting to determine the validity of alleged overpayments can divert significant time from direct patient care, which results in lost practice revenue. All too frequently, overpayment demands are made in the most general terms; the practice is not given the specific information—such as dates of service, patient names, or individual claims—which would enable the practice to determine independently the validity of the demand. Overpayment demands may also be intimidating, particularly when the amounts alleged are significant. Such amounts are frequently the result of "extrapolated" audits. Sizable demands may also reflect a payer’s contention that alleged overpayments have been occurring over many years.

The AMA has created "Questions to consider when addressing payer overpayment recovery requests on individual claims" to help you handle overpayment recovery issues.

Challenging overpayment allegations

Overpayment allegations can frequently be successfully challenged. Insurers may, for example, request overpayments of dubious legitimacy, hoping that the practice will simply concede. Although this may resolve a particular set of allegations, ready acquiescence may fix the practice as an "easy mark" to which an insurer may return with further demands. Informed opposition, even if not always entirely successful, may lead the practice to develop a better process for identifying overpayments,, as well as confirm for the insurer that the practice is not an "easy mark."
Federal and state regulations may help practices oppose or otherwise limit the effectiveness of overpayment demands. For example, a number of states limit the "look back" period over which insurers may claim overpayments. Many states also require insurers to provide specific information enabling physicians to determine independently the validity of demands prior to recoupment. The AMA has also successfully lobbied for significant limitations on the authority that certain government contractors (for instance, Medicare and Medicaid Recovery Audit Contractors) may exercise when pursing physician practices for alleged overpayments.

Read more about the AMA’s advocacy with respect to the Medicare and Medicaid Recovery Audit Contractor Programs.

 

New Medicare overpayment obligations under the Patient Protection & Affordable Care Act

Repayment is even more important now, since the Patient Protection and Affordable Care Act (ACA) imposed a new Medicare repayment obligation on physicians and providers. Under the ACA, a physician practice must report and repay a Medicare overpayment no later than sixty (60) days after the date on which the practice identified the overpayment. Failure to report and repay the overpayment within this deadline may result in significant monetary and administrative penalties. Physician practices should have in place procedures for repaying identified overpayments to all payers as a matter of good business practice.
For more information on AMA’s advocacy with respect to the 60-day repayment obligation, refer to the Fraud and Abuse section on the Advocacy with the Administration webpage.

Article Courtesy of: AMA- http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/claims-revenue-cycle/overpayment-recovery.page
 

How to Code, Negotiate After-Hours Reimbursement at Your Practice

There are codes in the CPT® code book to report services a physician provides during "nontraditional" hours. If you prove that it’s in the payer’s best interest, third-party insurers may allow additional reimbursement for after-hours services.

Medicare and payers that strictly follow CMS guidelines will not pay additional reimbursement for after-hours services. However, you might succeed with private payers in negotiating payment for after-hours codes as part of a contractual agreement, especially if you use savings potential as leverage. Have your negotiator make it clear to the insurer’s representative that you’ll willingly send patients to the emergency department (ED) instead of offering in-office after-hours services, but that ED services can cost as much as 10 times more than comparable physician services.

To further demonstrate cost savings, you could also start billing all applicable after-hours codes for your practice. Over time, you will have compiled an archive of claimed charges, which you can use to show the insurer how often you provide these services. In this report to the insurer, consider adding data on the much higher price of ED visits for the same services.

Know the Codes

Based on the CPT®/AMA guidelines, you may report 99050 — Services provided in the office at time other than regularly scheduled office hours, or days when the office is closed (e.g., holidays Saturday or Sunday), in addition to basic service — for any service provided in the office at a time when the practice would normally be closed (e.g., weekends or evenings). Code 99050 is reported in addition to the code for the basic service.

If your practice already maintains regular hours on evenings, weekends, or holidays, and you provide a service during those times, you should skip 99050 and use 99051 — Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.

If a 24-hour facility requests that your physician provide a redeye or early-bird service, AMA guidelines allow you to claim 99053 — Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24-hour facility, in addition to basic service, in addition to the basic service. Code 99053 can be used whether the provider is already at the facility, or if the physician has to make a special trip to care for the patient. The code 99053 can only be used if the service provided occurs at a 24-hour facility, such as an ambulatory surgical center (POS 24), urgent care facility (POS 20), or emergency department (POS 23).

Emergency department physicians may report 99053 for services rendered between the hours of 10 p.m. and 8 a.m. The American College of Emergency Physicians fully supports this use of 99053, stating that this code is appropriate for late-night services, "especially given the nighttime practitioner availability costs typically incurred by all medical practices, including emergency medicine."

Article written by: By G. John Verhovshek, MA, CPC from: http://www.physicianspractice.com/blog/how-code-negotiate-after-hours-reimbursement-your-practice?utm_source=dlvr.it&utm_medium=twitter&mkt_tok=3RkMMJWWfF9wsRoluqXKZKXonjHpfsX57ugqXKS3lMI/0ER3fOvrPUfGjI4ETMNrI%2BSLDwEYGJlv6SgFSbXHMbl60bgMUhg%3D

Being a member of the American Medical Association

Your AMA membership allows you to:

• Build your knowledge and keep it current. Full access to AMA publications is included.
• Share your perspective and make a difference. Get involved in the work that matters to your profession.
• Gain expert support to help you with your practice and your career.
• Enjoy special savings on insurance, financial services, medical supplies, travel and more.

https://commerce.ama-assn.org/membership/

Courtesy of: http://www.ama-assn.org/ama/pub/membership/membership-benefits.page?

American Medical Assn. V. United Healthcare

http://www.youtube.com/watch?feature=player_detailpage&list=PL76E72A2E143FAD10&v=8VXig5TvxK0

House bill would stop ICD-10 mandate

Legislation introduced in the U.S. House would prohibit the Dept. of Health and Human Services from mandating that physicians use ICD-10 diagnosis codes beginning Oct. 1, 2014.

The bill, the Cutting Costly Codes Act of 2013, would stop the required transition to new diagnosis code sets by physicians who are billing for medical services, verifying patient eligibility, obtaining pre-authorizations, documenting patient visits, and conducting both public health reporting and quality reporting. The mandated switch to the 68,000-code system had been established in a 2009 regulation. HHS announced in 2012 that its implementation deadline had been delayed by one year to 2014.

The American Medical Association wrote an April 26 letter to Rep. Ted Poe (R, Texas) in support of his legislation. Physician practices must bear the cost of training, software upgrades and testing of the new system. The projected cost of ICD-10 implementation ranges from $83,290 to more than $2.7 million per practice, the AMA letter stated.

“The timing of the ICD-10 transition could not be worse, as many physicians are currently spending significant time and resources implementing electronic health records into their practices,” the AMA said. “Physicians are also facing present and future financial burdens in the form of penalties if they do not successfully participate in multiple Medicare programs already under way, including e-prescribing, EHR meaningful use, the physician quality reporting system and value-based modifier programs.”

The House legislation also would authorize the Government Accountability Office to study ICD-10 and recommend ways to mitigate upgrade disruptions within the health care system.

 

This article courtesy of: http://www.amednews.com/article/20130513/government/130519980/10/?utm_source=rss&utm_medium=&utm_campaign=20130708

 

AMA meeting: Insurer report card points to patient collection hassles

A change to the American Medical Association's annual National Insurer Report Card reflects a growing burden physicians face when it comes to getting paid — collecting the patient portion.

Since its launch in 2008, the AMA's annual report card has revealed the physicians' burdens when it comes to getting paid by insurers. In the 2013 report, released during the AMA Annual Meeting in June, analysts calculated the percentage of the medical bill for which patients are responsible for paying through co-payments, deductibles and coinsurance and found that it accounts for nearly one-quarter of medical bills overall. Humana had the lowest patient responsibility at 15%, and Health Care Service Corp. had the highest at 29.2%.

The report was based on claims data from services submitted in February and March from Aetna, Anthem Blue Cross Blue Shield, Cigna, HCSC, Humana, Regence, UnitedHealthcare and Medicare.

“For physicians used to getting payments exclusively from insurers, increased patient cost responsibility poses new challenges,” said Mark Rieger, vice president of payment and reimbursement strategy for National Healthcare Exchange Services, a compliance and denial management solutions provider in Sacramento, Calif., that supplied most of the data used in the analysis.

“Physicians are basically not very good at collecting the patient responsibility. And this is a problem, overall, because as the burden shifts more to patients, more of your revenue is at risk,” Rieger said.

Because this was the first year the report looked at the patient portion, it did not provide historical context for the rise in patient responsibility. But a November 2012 Kaiser Family Foundation report showed that the percentage of workers covered by a plan that includes a deductible rose from 52% in 2006 to 72% in 2012. Those who were in such a plan saw deductibles rise from an estimated average of $584 to $1,097 during the same period.

The problem for physicians, says the AMA, is that they don't always know what the patient portion is at the time of care, making it difficult to collect during the visit. That's when patients are most likely to pay, and it also saves the physicians the cost of chasing down bills.

“Physicians want to provide patients with their individual out-of-pocket costs but must work through a maze of complex insurer rules to find useful information,” said AMA Board of Trustees Member Barbara L. McAneny, MD. “The AMA is calling on insurers to provide physicians with better tools that can automatically determine a patient's payment responsibility prior to treatment.”

The patient portion piece was just one of the many areas of claims adjudication that could benefit from streamlining technology, the report card found. The electronic submission of claims, for example, could reduce the amount of time for claims to be received by insurers.

Health plans said it also falls to doctors to ensure that their systems are ready for faster claims adjudication.

“Health plans and providers share the responsibility of improving the accuracy and efficiency of claims payment. Health plans are doing their part to streamline health care administration to reduce paperwork, improve efficiency and bring down costs,” said Robert Zirkelbach, spokesman for America's Health Insurance Plans, the trade group representing health plans. “At the same time, more work needs to be done to increase electronic submission of claims and to reduce the number of claims submitted to health plans that are duplicative, inaccurate or delayed.”

DID YOU KNOW:
72% of workers with health insurance in 2012 had a plan that included a deductible, up from 52% in 2006.

For example, Zirkelbach pointed to a February AHIP survey that found 16% of electronic claims and 54% of paper claims were received from a physician or hospital more than 30 days after the service date.

Administrative burdens quantified

Along with the annual report card, the AMA also launched its Administrative Burden Index. It examined the claims that required reworking and calculated a monetary amount of each reworked claim, per each evaluated health plan. A five-star rating system also was designed to highlight areas that need focus.

The index found that HCSC had the highest cost associated with the reworking of claims at $3.32 per claim. Cigna had the lowest at $1.25 per claim.

A typical physician practice will lose $14,600 each year on claims reworked to address insurer denials, said Frank Cohen, senior analyst for Frank Cohen Group, a data analytics firm in Clearwater, Fla., that helped create the report card and the burdens index.

In an emailed statement to American Medical News, HCSC spokesman Greg Thompson said his company, which runs nonprofit BlueCross BlueShield plans in Illinois, New Mexico, Oklahoma and Texas, conducts quality reviews and audits regularly to evaluate and monitor performance. It also is investing in technology and encouraging doctors to file more claims electronically.

“According to our record, we process claims accurately more than 99% of the time,” Thompson said. He said that although the company is proud of the work it has done evaluating and improving claims process efficiencies, “we welcome the AMA and others to reduce the administrative burdens and improve efficiencies in our health care system.”

Thompson said the company was reviewing the report card and the index, and did not have reaction to specific findings.

This article courtesy of: http://www.amednews.com/article/20130701/house/130709968/4/?utm_source=rss&utm_medium=&utm_campaign=20130708

 

What is a CPT code?

What is CPT?
Current Procedural Terminology (CPT®), Fourth Edition, is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians and other healthcare providers, patients, and third parties.

How is CPT used?
CPT descriptive terms and identifying codes currently serve a wide variety of important functions. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT is also used for administrative management purposes such as claims processing and developing guidelines for medical care review.
The uniform language is also applicable to medical education and research by providing a useful basis for local, regional, and national utilization comparisons.

How was CPT developed?
The American Medical Association (AMA) first developed and published CPT in 1966. The first edition helped encourage the use of standard terms and descriptors to document procedures in the medical record; helped communicate accurate information on procedures and services to agencies concerned with insurance claims; provided the basis for a computer oriented system to evaluate operative procedures; and contributed basic information for actuarial and statistical purposes.
The first edition of CPT contained primarily surgical procedures, with limited sections on medicine, radiology, and laboratory procedures. The second edition was published in 1970 and presented an expanded system of terms and codes to designate diagnostic and therapeutic procedures in surgery, medicine, and the specialties. At that time, a five-digit coding system was introduced, replacing the former four-digit classification. Another significant change was a listing of procedures relating to internal medicine.
In the mid to late 1970s, the third and fourth editions of CPT were introduced. The fourth edition, published in 1977, represented significant updates in medical technology, and a system of periodic updating was introduced to keep pace with the rapidly changing medical environment. In 1983 CPT was adopted as part of the Centers for Medicare and Medicaid Services (CMS), formerly Health Care Financing Administration's (HCFA), Healthcare Common Procedure Coding System (HCPCS). With this adoption, CMS mandated the use of HCPCS to report services for Part B of the Medicare Program. In October 1986, CMS also required state Medicaid agencies to use HCPCS in the Medicaid Management Information System. In July 1987, as part of the Omnibus Budget Reconciliation Act, CMS mandated the use of CPT for reporting outpatient hospital surgical procedures.
Today, in addition to use in federal programs (Medicare and Medicaid), CPT is used extensively throughout the United States as the preferred system of coding and describing health care services.

HIPAA and CPT
The Administrative Simplification Section of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the Department of Health and Human Services to name national standards for electronic transaction of health care information. This includes transactions and code sets, national provider identifier, national employer identifier, security and privacy. The Final Rule for transactions and code sets was issued on August 17, 2000. The rule names CPT (including codes and modifiers) and HCPCS as the procedure code set for:

• Physician services.
• Physical and occupational therapy services.
• Radiological procedures.
• Clinical laboratory tests.
• Other medical diagnostic procedures.
• Hearing and vision services.
• Transportation services including ambulance.

The Final Rule also named ICD-9-CM volumes 1 and 2 as the code set for diagnosis codes, ICD-9-CM volume 3 for inpatient hospital services, CDT for dental services, and NDC codes for drugs.
All health care plans and providers who transmit information electronically were required to use established national standards by the end of the implementation period, October 16, 2003. In addition, all local codes were eliminated and national standard code sets were required for use after October 16, 2003.

Who Maintains CPT?
The CPT Editorial Panel is responsible for maintaining the CPT code set. This panel is authorized by the AMA Board of Trustees to revise, update, or modify CPT codes, descriptors, rules and guidelines. The Panel is comprised 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: the Blue Cross and Blue Shield Association, America's Health Insurance Plans, the American Hospital Association, and the Centers for Medicare and Medicaid Services (CMS). The remaining two seats on the CPT Editorial Panel are reserved for members of the CPT Health Care Professionals Advisory Committee.
Five members of the Editorial Panel serve as the panel's Executive Committee. The Executive Committee includes the Editorial Panel chairman, co-chairman and three panel members-at-large, as elected by the entire panel. One of the three members-at-large of the executive committee must be a third-party payer representative.
Supporting the CPT Editorial Panel in its work is a larger body of CPT advisors, the CPT Advisory Committee. The members of this committee are primarily physicians nominated by the national medical specialty societies represented in the AMA House of Delegates. Currently, the Advisory Committee is limited to national medical specialty societies seated in the AMA House of Delegates and to the AMA Health Care Professionals Advisory Committee (HCPAC), organizations representing limited-license practitioners and other allied health professionals. Additionally, a group of individuals, the Performance Measures Advisory Group (PMAG), who represent various organizations concerned with performance measures, also provides expertise.
The Advisory Committees' primary objectives are to:

• serve as a resource to the CPT Editorial Panel by giving advice on procedure coding and appropriate nomenclature as relevant to the member's specialty;
• provide documentation to staff and the CPT Editorial Panel regarding the medical appropriateness of various medical and surgical procedures under consideration for inclusion in CPT;
• suggest revisions to CPT. The Advisory Committee meets annually at the CPT Fall meeting to discuss items of mutual concern and to keep abreast of current issues in coding and nomenclature;
• assist in the review and further development of relevant coding issues and in the preparation of technical education material and articles pertaining to CPT; and
• promote and educate its membership on the use and benefits of CPT.

How are requests for changes to CPT reviewed?
Specific procedures exist for addressing requests to revise CPT, such as adding or deleting a code, or modifying existing nomenclature.
Medical specialty societies, individual physicians, hospitals, third-party payers and other interested parties may submit applications for changes to CPT for consideration by the Editorial Panel. The AMA’s CPT staff reviews all requests to revise CPT including applications for new and revised codes. If AMA staff determines that the Panel has already addressed the question, staff informs the requestor of the Panel's coding recommendation. However, if staff determines that the request presents a new issue or significant new information on an item that the Panel reviewed previously, the application is referred to members of the CPT Advisory Committee for evaluation and commentary. Applications that have not received any CPT Advisor support will be presented to the CPT Editorial Panel for discussion and possible decision unless withdrawn by the applicant. Applicants will be notified if their applications have received no CPT Advisor support approximately 14 days prior to each meeting of the CPT Editorial Panel meeting. Applicants have the ability to withdraw their applications up until the agenda item is called at the meeting—thereafter the CPT Editorial Panel has jurisdiction over the agenda item.
The CPT Editorial Panel meets three times each year. AMA staff prepares agenda materials for each CPT Editorial Panel meeting. Panel members receive agenda material at least 30 days in advance of each meeting, allowing them time to review the material, review CPT Advisor comments and confer with experts on each subject, as appropriate. The Panel addresses nearly 350 major topics a year, which typically involve more than 3,000 votes on individual items.
A multi-step process naturally means that deadlines are very important. The deadlines for submitting code change applications and for compilation of CPT Advisors’ comments are based on a schedule which allows at least three months of preparation and processing time before the issue is ready for review by the CPT Editorial Panel. The initial step, which includes AMA staff and CPT Advisor review, is completed when all appropriate CPT Advisors have been contacted and have responded, and all information requested of an applicant has been provided to AMA staff.
Following review and compilation of CPT Advisors’ comments, AMA staff prepares an agenda item that includes the application, compiled CPT Advisor comments and a ballot for decision by the CPT Editorial Panel. Once the Panel has taken an action and preliminarily approved the minutes of the meeting, AMA staff informs the applicant of the outcome.
The Panel actions on an agenda item can result in one of four outcomes:

• addition of a new code or revision of existing nomenclature, in which case the change would appear in a forthcoming volume of CPT;
• referral to a workgroup for further study;
• postponement to a future meeting (to allow submittal of additional information in a new application); or
• rejection of the item.

Applicants or other interested parties who wish to seek reconsideration of the Panel's decision should refer to the process described on the AMA/CPT website.

Category I CPT codes
Category I CPT codes consist of a five-digit CPT code and descriptor nomenclature which describes in detail the medical procedure or service. New or revised codes (including a previously assigned Category III code[s]) are assigned Category I status if the CPT Editorial Panel determines, based on the evidence submitted:

• that the service/procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;
• that the suggested procedure/service is a distinct service performed by many physicians/practitioners across the United States;
• that the clinical efficacy of the service/procedure is well established and documented in U.S. peer review literature;
• that the suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes; and
• that the suggested service/procedure is not requested as a means to report extraordinary circumstances related to the performance of a procedure/service already having a specific CPT code.

Category II CPT codes- Performance Measurement
CPT Category II codes are supplemental tracking codes that can be used for performance measurement. The use of the tracking codes for performance measurement will decrease the need for record abstraction and chart review, and thereby minimize administrative burdens on physicians and other health care professionals. These codes are intended to facilitate data collection about quality of care by coding certain services and/or test results that support performance measures and that have been agreed upon as contributing to good patient care. Some codes in this category may relate to compliance by the health care professional with state or federal law.
The use of these codes is optional. The codes are not required for correct coding and may not be used as a substitute for Category I codes.
Services/procedures or test results described in this category make use of alpha characters as the 5th character in the string (i.e., 4 digits followed by an alpha character). These digits are not intended to reflect the placement of the code in the regular (Category I) part of the CPT code set. Also, these codes describe components that are typically included in an evaluation and management service or test results that are part of the laboratory test/procedure. Consequently, they do not have a relative value associated with them.
Tracking codes for performance measurement are released three times yearly following approval of the Panel minutes after each Editorial Panel meeting (March 15th, July 15th, and November 15th) on the AMA CPT Category II website, and published annually in the CPT book as part of the general CPT code set.
Tracking codes are reviewed by the Performance Measures Advisory Group (PMAG), an advisory body to the CPT Editorial Panel and the CPT Health Care Professionals Advisory Committee (CPT/HCPAC). The PMAG is comprised of performance measurement experts representing the Agency of Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA), and the Physician Consortium for Performance Improvement. The PMAG may seek additional expertise and/or input from other national health care organizations as necessary for the development of tracking codes. These may include national medical specialty societies, other national health care professional associations, accrediting bodies, and federal regulatory agencies. PMAG recommendations are then forwarded to the CPT/HCPAC Advisory Committee just as requests for Category I CPT codes are reviewed. The PMAG is interested in:

• measurements that have been developed and tested by a national organization;
• evidence-based measurements with established ties to health outcomes;
• measurements that address clinical conditions of high prevalence, high risk or high cost; and
• well-established measurements that are currently used by large segments of the health care industry

Category III CPT codes- Emerging Technology
Category III CPT codes are a temporary set of tracking codes for new and emerging technologies. These codes are intended to facilitate data collection on and assessment of new services and procedures. The Category III codes are intended for data collection purposes in the FDA approval process or to substantiate widespread usage. As such, the Category III codes may not conform to the usual CPT code requirements for Category I. The Panel has established the following criteria for evaluating Category III code requests, any one of which is sufficient for consideration by the Editorial Panel:

1. a protocol for a study of procedures being performed;
2. support from the specialties who would use the procedure;
3. availability of U.S. peer-reviewed literature;
4. descriptions of current United States trials outlining the efficacy of the procedure.

In general, these codes will be assigned a numeric-alpha identifier (eg, 1234T). These codes will be located in a separate section of CPT, following the "Category II" section. Introductory language in this code section explains the purpose of the Category III codes.
Since Category III CPT codes are intended to be used for data collection purposes to substantiate widespread usage or in the FDA approval process, they are not intended for services/procedures that are not accepted by the Editorial Panel because the proposal was incomplete, more information was needed, or the Advisory Committee did not support the proposal.
Once approved by the Editorial Panel, the newly added Category III CPT codes are released biannually (January 1 and July 1) on the AMA CPT Category III website (http://www.ama-assn.org/go/cpt-cat3) and published annually in the CPT book as part of the general CPT code set. Codes released on January 1st are effective July 1st, allowing 6 months for implementation, and codes released on July 1st are effective January 1st.
Category III CPT codes are not referred to the AMA/Specialty RVS Update Committee (RUC) for valuation because no relative value units (RVUs) will be assigned. Payment for these services/procedures is based on the policies of payers and local Medicare Carriers. However, the assignment of a CPT Category III code to a service does not indicate that it is experimental or of limited utility, but only that the service or technology is new and is being tracked for data collection. In the Final Rule for the 2002 Medicare Physician Fee Schedule (Federal Register, Thursday, November 1, 2001), the Center for Medicare and Medicaid Services (CMS) stated that they believed that Category III codes will serve a useful purpose and that payment for the service is at the discretion of the Carriers, but that the codes could be paid after entered into the computer systems. Local payment determination is reasonable for Category III CPT codes. It is not reasonable to categorically deny payment for CPT Category III codes since they are effectively more specific, more functional versions of unlisted codes which many payers cover with appropriate documentation. Once payment policies are established of a Category III Code, the need for documentation will be minimized since Category III Codes are associated with unique and specific descriptions of the service or procedure. Since Category III codes are part of the CPT code set, all health care payers must be able to accept Category III codes into their systems to comply with the standards for transactions and code sets under HIPAA.
In general, these codes will be archived 5 years from the date of implementation if the code has not been accepted for placement in the Category I section of CPT, unless it is demonstrated that a Category III code is still needed. These codes will not be reused.

When are CPT codes implimented?
As the designated standard for the electronic reporting of physician and other health care professional services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), CPT codes are updated annually and effective for use on January 1 of each year. The AMA prepares each annual update so that the new CPT books are available in the fall of each year preceding their effective date to allow for implementation.
Category I vaccine product codes, Molecular Pathology and Category III codes are typically "early released" for reporting either January 1st or July 1st of a given CPT cycle. In order to comply with HIPAA requirements, the effective dates for these codes have been altered to become effective six months subsequent to the date of release following code set updates. As a result, codes released on January 1st are effective July 1st, allowing 6 months for implementation, and codes released on July 1st are effective January 1st.
Category II codes are typically "early released" for reporting three times yearly (March 15th, July 15th, and November 15th) following approval of the Panel minutes after each Editorial Panel meeting. The effective dates for these codes have also been altered to become effective three months subsequent to the date of release following code set updates. For example, codes released on July 15th are effective October 15th, allowing 3 months for implementation.

This article courtesty of: American Medical Assn. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-process-faq/code-becomes-cpt.page