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:
- a protocol for a study of procedures being performed;
- support from the specialties who would use the procedure;
- availability of U.S. peer-reviewed literature;
- 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
.
