Behind the Scenes: The Making of CPT®

Behind the Scenes: The Making of CPT®

Updating CPT® every year is a job for the CPT Editorial Panel, many stakeholders, and you.

CPT® is the most widely accepted procedural coding medical nomenclature used across the country. For more than 50 years, physicians and other healthcare professionals have relied on the CPT® code set to communicate with colleagues, patients, hospitals, and insurers about the procedures they have performed. Although the code set itself is established and well known, the time, expertise, and overall contributions of many parties that play a role in their creation may not be as well known. To ensure the code set meets the demands of its many users, there is a constant and growing need to modernize and innovate CPT® continuously.

Who Plays a Role in Creation and Maintenance?

The CPT Editorial Panel

  • The CPT Editorial Panel has the responsibility for the maintenance of the CPT® code set. The panel is comprised of 17 voting members, with the following composition:
    11 physicians appointed by the national medical societies and approved by the American Medical Association (AMA) House of Delegates (HoD);
  • One American Hospital Association (AHA) representative;
  • Three physician payer representatives from the Blue Cross and Blue Shield (BCBS) Association, America’s Health Insurance Plans (AHIP), and the Centers for Medicare & Medicaid Services (CMS); and
  • Two non-doctor of medicine/non-doctor of osteopathic medicine representatives from the Health Care Professionals Advisory Committee (HCPAC).

Although CPT Editorial Panel members represent a diverse range of medical specialties, they do not represent their own specialty; rather, they provide their own independent judgment to maintain the integrity of the CPT® code set.

In addition to these voting members, the panel relies on coding experts from AAPC, the American Health Information Management Association (AHIMA), and AHIP, AHA, and the BCBS Association to provide important input and assure professional coders’ concerns are addressed in the panel’s deliberation process.
The CPT Editorial Panel has the authority to revise, update, or modify CPT®. It is the responsibility of the panel to ensure CPT® codes reflect contemporary medical care provided to patients. To facilitate these responsibilities, the panel meetings are open to all public stakeholders. The panel agenda is available on the AMA CPT® public website. Although monitoring is-sues discussed at the meeting is open to all, the actual meeting agenda materials are confidential.

The CPT Editorial Panel meets three times per year to gather input from practicing physicians, medical device manufacturers, developers of the latest diagnostic tests, and advisers from over 100 societies representing physicians and other qualified healthcare professionals. Although most professional coders and healthcare providers are familiar with traditional (Category I) and Emerging Technology (Category III) codes, many may be surprised to know the panel is also responsible for managing CPT® vaccine codes, Category II, Administrative Multianalyte Assays with Algorithmic Analyses (MAAA), and Proprietary Laboratory Analysis (PLA) codes.

The CPT Advisory Committee

The CPT Advisory Committee is made up of over 180 physicians and other qualified healthcare professionals nominated by their respective national medical specialty societies. The primary objectives of the Advisory Committee are:

  • To serve as a resource to the Editorial Panel by advising them on procedure coding and nomenclature as relevant to the member’s specialty;
  • To provide documentation to AMA staff and the CPT Editorial Panel regarding medical appropriateness of medical and surgical procedures being considered for inclusion in the CPT® code set;
  • To suggest revisions to CPT®;
  • To assist in reviewing and developing relevant coding issues, and in preparing technical CPT® code set education material and articles; and
  • To promote and educate its membership on the use and benefits of the CPT® code set. The input of the advisers is an integral part of CPT® review process optimization.

Maintenance Holds a Tight Time Schedule

Each year, the CPT® Editorial Panel sets an aggressive schedule to ensure the code set is released in a manner that meets the needs of a diverse stakeholder base. Although many people believe the code set is only updated once per year, in fact the code set receives quarterly updates. Each code set is released at a prior date than its effective date. This allows payers, vendors, and providers to implement the codes into their systems prior to the effective date. Although the release schedule is complex, it assures a timely release of new codes to keep CPT® contemporary.

The release schedule for various categories of codes:

  • Category I codes are released on Aug. 31 and effective Jan. 1.
  • Vaccine, Category II, and Category III codes are released bi-annually, on Jan. 1 and July 1, and are effective six months following their release.
    Molecular Pathology Tier 2 and MAAA codes are released tri-annually on March 1, Sept. 1, and Dec. 1, and are effective one month following each release.
  • The newest category of CPT® codes, the Proprietary Laboratory Analysis (PLA) codes, are released April 1, July 1, Oct. 1, and Jan. 1, and are effective the following quarter after release.

The Role of Education

The mission of the CPT® Assistant Editorial Board is to assist the CPT Editorial Panel in advancing accurate and consistent use of the CPT® code set by establishing stakeholder consensus to provide clear interpretation of CPT® coding issues. Through the efforts of the board, CPT® Assistant conveys the standard for proper coding and reporting of procedures and services described by the CPT® code set.

The CPT® Assistant Editorial Board is led by the vice-chair of the CPT Editorial Panel and is comprised of six physician members from both the CPT Advisory Committee and current or former members of the panel, one physician representative from the AMA/Specialty Society Relative Value Update Committee (RUC) and five non-physician coding experts from AHIP, AHA, CMS, and BCBS Association.

The CPT® Assistant Editorial Board gives stakeholders from across the healthcare landscape the opportunity for formal input into the process of selecting topics for articles, reviewing the publication’s coding content, and contributing content for publication. Due to the complexity of the CPT® code set and the potential for differences in interpretation, the role of CPT® Assistant is to clarify appropriate use of the code set. Note: CPT® Assistant does not redefine the use of CPT® codes contrary to the guidelines set forth in the CPT®, rather the board has the challenging task of balancing AMA interpretation and “real world” coding practices. It’s critical for CPT® Assistant to evolve to meet this demand without losing its identity as the AMA’s official interpretation of CPT® coding practices.

On occasion during CPT® Assistant Editorial Board discussions, an issue arises which demonstrates changes in code application, new procedures being submitted with an established code, or lack of clarity in CPT® that requires more than an educational endeavor. These issues are referred by the CPT® Assistant Editorial Board to the CPT Editorial Panel. If the issue can be clarified without modifications to the code structure, a CPT® Assistant article may be written which incorporates that clarification. If the issue merits a new coding solution and modifications or additions of introductory guidelines or parenthetical notes, the relevant specialty societies are directed to submit a code change application through the AMA’s Code Change Application Submission website to resolve the issue. The board’s close relationship with the panel and the specialty societies ensures educational content of the CPT® code set remains clear and accurate.

AMA/Specialty Society Relative Value Scale Update Committee

RUC is composed of members representing the AMA and national medical specialty societies, who make recommendations to CMS on assigning relative values to applicable new and revised CPT® codes, as they are adopted by the AMA CPT Editorial Panel. These relative values in the resource-based relative value scale (RBRVS) for physician work, practice expense, and professional liability insurance components were developed to correspond to the procedure definitions within the CPT® code book. From the AMA’s perspective, RUC provides a vital opportunity for the medical profession to continue providing appropriate input to the physician payment environment. For this reason, the AMA has strongly advocated that Medicare adopt RUC’s recommendations.

Innovation to Meet Stakeholder Needs

As medicine evolves with clinical innovations (i.e., personalized genomic testing, digital medicine, and considerations of physician work and augmented intelligence intersection) the AMA and the panel remain committed to developing a code set that establishes the language for medical innovation. A recent example of this work is the creation of PLA codes. The CPT Editorial Panel created these codes in response to the Protecting Access to Medicare Act of 2014, defining advanced diagnostic laboratory tests and clinical diagnostic laboratory tests. This solution was designed to meet the needs of regulators and of manufacturers and laboratories proving these novel tests. The PLA code set began development in 2016 and the first codes were published in the 2018 CPT® code book.

As healthcare innovation keeps growing, the CPT® process has adapted to this new stakeholder in the procedural coding space with the advent of the “Interested Party” process. This process allows other individuals and groups outside of the traditional CPT® process to review non-proprietary application materials and opine on the appropriateness of code application for CPT Editorial Panel review, again to strengthen CPT® integrity.

There are numerous parties and many checks and balances that play an important role in determining the content of the CPT® code set. These parties were carefully orchestrated to tap into the wide-ranging expertise of the above-mentioned bodies. Code book users can be assured that every effort is made to ensure quality, accuracy, and timeliness of the CPT® code set.

Anyone can get involved in putting their ideas and experience to good use in the ongoing maintenance of the CPT® code set. To see how, visit the AMA website.


Written by:
Mark S. Synovec, MD, serves as chairman, CPT Assistant Editorial Board and vice chair, CPT Editorial Panel. He is an anatomic and clinical pathologist, is the president of Topeka Pathology Group, LLC and medical director of Stormont-Vail Healthcare Laboratories. Dr. Synovec has been involved in the laboratory topics in the CPT® code set, beginning as the past AMA’s CPT® advisor representing the American Society of Clinical Pathology in 1995 and past chair of the AMA CPT® Pathology Coding Caucus. He was appointed to serve on the AMA CPT Editorial Panel in June 2007 and the AMA CPT Editorial Panel Executive Committee in June 2011. Dr. Synovec is the Pathology Section Council chair to the AMA HoD, where he serves as a delegate for the College of American Pathologists. He served as co-chair of the CPT® Molecular Pathology Advisory Committee (MPAG).
Resources:
CPT® Editorial Panel agenda:
www.ama-assn.org/practice-management/cpt-upcoming-meetings-calendar
AMA’s Code Change Application Submission:
www.ama-assn.org/practice-management/cpt-code-applications-criteria
Put your ideas and experience to good use in the maintenance of the CPT® code set at:
www.ama-assn.org/cpt

 

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