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Adv Wound Care (New Rochelle). 2013 Dec; 2(10): 583–587.

CPT^® Codes: What Are They, Why Are They Necessary, and How Are They Developed?

Received 2013 Jul 22; Accepted 2013 Oct 9.

Abstract

Qualified healthcare professionals (QHPs) demand to place the professional services they provide and to written report those services in a mode that tin be universally understood by institutions, private and government payers, researchers, and others interested parties. The QHPs' data are used to rail healthcare utilization, place services for payment, and to gather statistical healthcare information about populations. Each year, in the United states of america, healthcare insurers procedure over v billion claims for payment.¹ To ensure that healthcare data are captured accurately and consistently and that health claims are candy properly for Medicare, Medicaid, and other health programs, a standardized coding system for medical services and procedures is essential. The Current Procedural Terminology (CPT^®) arrangement, developed by the American Medical Association (AMA), is used for only these purposes. The AMA organization provides a standard language and numerical coding methodology to accurately communicate across many stakeholders, including patients, the medical, surgical, diagnostic, and therapeutic services provided by QHPs. The CPT descriptive terminology and associated code numbers provide the most widely accepted medical nomenclature used to report medical procedures and services for processing claims, conducting research, evaluating healthcare utilization, and developing medical guidelines and other forms of healthcare documentation.

Groundwork

History of Electric current Procedural Terminology coding development

The get-go publication, in 1966, of the American Medical Association (AMA) Current Procedural Terminology (CPT^®) edition of standardized codes and terms was a ways to lawmaking procedures (mainly surgical) for medical records, insurance claims, and data for statistical purposes.

By 1970, the AMA had broadened the organisation of terms and nomenclature codes to include diagnostic and therapeutic procedures in surgery, medicine, and the specialties as well every bit procedures relating to internal medicine. This timeframe also coincided with the introduction of the 5-digit numeric coding organisation. With the release of the fourth edition of CPT in 1977, the AMA introduced a system for periodic updating of the codes to go on up with the ever-changing medical surround.

In 1983, CPT was adopted as part of the Centers for Medicare & Medicaid Services (CMS), Healthcare Mutual Procedure Coding Arrangement (HCPCS). This HCPCS code set is divided into two main subsystems: (one) Level I of the HCPCS, which comprised the CPT and (2) Level Two of the HCPCS (come across Marcia Nusgart'due south commodity).^one,2

Level I CPT codes are the numerical codes used primarily to identify medical services and procedures furnished by qualified healthcare professionals (QHPs). CPT does not include codes regularly billed past medical suppliers other than QHPs to written report medical items or services. The AMA is responsible for all decisions for additions, deletions, or revisions of the CPT codes [Level I HCPCS code gear up]. CPT codes are updated annually.

In 1983, CMS mandated that CPT codes be used to report services for Part B of the Medicare Program and in 1986 required state Medicaid programs to also use the CPT codes. Equally part of the Omnibus Upkeep Reconciliation Human action in 1987, CMS mandated apply of CPT for reporting outpatient hospital surgical procedures. As part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Department of Health and Human Services designated CPT and HCPCS as the national standards for electronic transaction of healthcare information.

Today, the CPT coding system is the preferred system for coding and describing healthcare services and procedures in federal programs (Medicare and Medicaid) and throughout the United States by private insurers and providers of healthcare services.

Types of CPT codes

The CPT lawmaking tin can exist identified by ane of the following three categories.

Category I CPT codes describe distinct medical procedures or services furnished by QHPs and are identified by a v-digit numeric code [e.g., 29580: Unna kick]. New Category I CPT codes are released annually.

Category II CPT codes are supplemental tracking codes, too referred to as performance measurement codes. These numeric alpha codes [e.g., 2029F: consummate concrete skin exam performed] are used to collect data related to quality of intendance. Category Ii codes are released iii times a twelvemonth in March, July, and Nov by the CPT Editorial Panel.

Category III CPT codes are temporary tracking codes for new and emerging technologies to let data collection and assessment of new services and procedures. They are used to collect data in the FDA approval process or to substantiate widespread usage of the new and emerging engineering science to justify establishment of a permanent Category I CPT code. Category III CPT codes are issued in a numeric alpha format [e.g., 0307T: near-infrared spectroscopy written report for lower extremity wounds].

New Category III CPT codes are released biannually (Jan and July) with a 6-calendar month filibuster earlier activation for implementation in the Medicare system. Codes released on Jan 1st are effective July 1st, and codes released on July 1st are effective January 1st. The codes usually remain active for five years from the date of implementation, if the code has not been accepted for placement in the Category I section of CPT.

Obtaining a CPT Level 3 lawmaking requires less clinical data and has a shorter review timeframe. Information technology allows billing and tracking through the local and regional contractors for Medicare and other payers. There are no assigned fees to these codes, just payment is available at the discretion of the Insurance Carriers or Medicare contractors. When considering payment, the Medicare contractors and insurers consider testify of effectiveness, improved outcomes, and potential cost savings.

Criteria used by the CPT Advisory Committee and the CPT Editorial Panel for evaluating Category III code for emerging technology include any ane of the following for consideration:

• i. A protocol for a report of procedures being performed.

• ii. Support from the specialties that would use the procedure.

• iii. Availability of U.S. peer-reviewed literature.

• iv. Descriptions of current U.S. trials outlining the efficacy of the procedure.

Give-and-take

Who manages the CPT process?

The responsibleness to update or modify code descriptors, coding rules, and guidelines for the CPT code set lies with the AMA CPT Editorial Panel, authorized by the AMA Board of Trustees. The panel comprised 17 members [11 physicians nominated by the national medical specialty societies; 4 physicians nominated from the Blue Cross and Blue Shield Clan, America'due south Health Insurance Plans, the American Hospital Association, and the CMS; and 2 seats reserved for members of the CPT Wellness Intendance Professionals Advisory Committee (HCPAC)]. Five of these members serve as the panel's Executive Committee. In add-on, the CPT Advisory Committee supports the panel. Members of CPT Advisory committee are primarily physicians nominated by the national medical specialty societies represented in the AMA House of Delegates besides as the AMA HCPAC, organizations representing limited license practitioners and other allied wellness professionals. The Functioning Measures Advisory Group, which represents diverse organizations concerned with performance measures, likewise provides expertise.

How is a new code developed?

Whatever individual QHP, medical specialty society, hospital, third-party payer, and other interested political party may submit an awarding for changes to CPT for new or revised codes to the CPT Editorial Console. This ongoing process has a schedule for submission deadlines and meetings of the CPT Console, which can exist institute on the AMA site.³ It is important to understand that an applicant needs to advisedly programme to submit their asking in the appropriate timeframe to coincide with the scheduled meetings for the CPT Editorial Console reviews.

Step 1: AMA staff determines if the request is new

If the Editorial Panel has already reviewed the request, the staff volition notify the requestor of the panel's coding recommendation. If the request is a new issue or includes meaning new information on an item that the panel reviewed previously, the application moves to footstep 2.

Stride ii: Refer application to the CPT Informational Committee for evaluation and commentary

The process allows at least 3 months for the AMA staff to set all the submitted materials and dispense them to the Editorial Panel reviewers. Steps 1 and 2 are complete when all appropriate CPT Advisors have responded and all information requested of an applicant has been provided to AMA.

Step three: Refer application to the CPT Editorial Panel

The 17 member CPT Editorial Panel meets three times each year and addresses well-nigh 350 major topics per twelvemonth, usually involving more than iii,000 votes on individual items.^four

• • AMA staff fix an calendar particular that includes the application, compiled CPT Advisor comments, and a ballot for decision by the CPT Editorial Panel.

• • Thirty days before a scheduled meeting, the panel members receive the agenda documents and the CPT Advisor comments. The console members can confer with experts as appropriate.

• • If an applicant does not receive the CPT Counselor back up, then the applicant is notified xiv days earlier each CPT Editorial Panel meeting. Applicants tin can withdraw their applications upwards until the agenda item is called at the coming together.

• • Applications that have not received any CPT Advisor support volition be presented to the CPT Editorial Panel for discussion and possible determination.

Pace four: CPT Editorial Panel takes an action and preliminary approvals

If applying for a Category I or Category III code, the CPT Editorial Console votes and determines into which category the lawmaking(s) should be assigned. A decision can consequence in 1 of the following iv outcomes:

• 1. Add a new code or revise the existing classification; this change would appear in a forthcoming book of the CPT Book.

• ii. Refer to a workgroup for further study.

• 3. Postpone to a future meeting [to allow submittal of additional information in a new application].

• four. Pass up the request.

Step 5: AMA staff inform the applicant of the CPT Editorial Panel's decision

Applicants or other interested parties can seek reconsideration of the panel'south conclusion. Data of this process is available on the AMA/CPT website.⁵

Stride half-dozen: Refer code to AMA/Specialty Order Relative Value Update Committee (RUC)

In one case the new/revised CPT codes are approved by the CPT Editorial Console, the lawmaking is then referred to the RUC, which volition conduct a survey of QHPs from relevant medical specialties that provide the service or process. This survey volition measure the QHP piece of work involved in performing the service/process to determine an authentic relative value recommendation for the service.^half-dozen The RUC committee schedule can be accessed at the AMA website.

Step 7: Implementation of the new/revised CPT code

• • Category I service and process CPT codes are updated annually and constructive for use on January 1 of each yr, except for Category I vaccine production codes, Molecular Pathology, which are released January 1st or July 1st. The new CPT volume, with the newly released codes, is released in the fall to allow for implementation on January 1.

• • Category 2 codes are released for reporting three times yearly (March 15th, July 15th, and Nov 15th) to become effective iii months subsequent to the date of release, allowing iii months for implementation.

• • Category Three codes are released for reporting either January 1st or July 1st of a given CPT cycle and become effective vi months subsequent to the date of release.

NOTE: This entire new CPT Lawmaking application process can have from 18 to 24 months.

What do the CPT Advisory Commission and CPT Editorial Panel need?

Success in obtaining a new or revised CPT code is dependent on agreement the process and preparing an application with the complete information required. Obtaining support from the appropriate medical community, society, or provider grouping that requires or endorses the need for the code is essential for the CPT approving process.

The major information requirements for a new or revised CPT lawmaking application include the post-obit.

• • A complete description of the process or service (east.thou., depict in particular the skill and fourth dimension involved. If a surgical process, include an operative report that describes the procedure in detail).

• • A clinical vignette, which describes the typical patient and piece of work provided by the physician/practitioner.

• • The diagnosis of patients for whom this procedure/service would be performed.

• • A copy(s) of peer reviewed manufactures published in the U.S. journals indicating the safety and effectiveness of the procedure.

• • Frequency with which the procedure is performed and/or estimation of its projected operation.

• • A copy(s) of boosted published literature, which further explains the request (due east.thou., practise parameters/guidelines or policy statements on a particular procedure/service).

• • Evidence of FDA approving of the drug or device used in the procedure/service if required.

• • Rationale why the existing codes are not adequate and can any existing codes be changed to include these new procedures without significantly affecting the extent of the service?

Where tin can I notice more than information?

The AMA website has all the information available concerning the CPT process, admission to the application forms, the schedule for the CPT Editorial Panel, and the reconsideration procedure forms.^seven

CPT is a registered trademark of the AMA.

Abbreviations and Acronyms

AMA	American Medical Clan
CMS	Centers for Medicare & Medicaid Services
CPT	Current Procedural Terminology
HCPCS	Healthcare Mutual Process Coding System
HIPAA	Health Insurance Portability and Accountability Human activity
QHP	qualified healthcare professional

Author Disclosure and Ghostwriting

No competing financial interests exist. No ghostwriters were used to write this article.

About the Author

Peggy Dotson, RN, BS, earned her nursing diploma in 1971 at Our Lady of Lourdes School of Nursing (Camden, NJ), and graduated from Philadelphia Academy (Philadelphia, PA) in 1993 with a Bachelor's of Scientific discipline caste. She has 9 years of feel in clinical practise working in surgical, coronary intendance, intensive care, and equally a field trainer for the Mercer County Paramedic Project in New Jersey. She worked for 23 years in Bristol-Myers Squibb's ConvaTec Partition in varying roles, including clinical trial monitor for ostomy, wound care, and incontinence devices; medical sales representative; sales management; international marketing; worldwide business concern development; and Director of Reimbursement & Payer Alliances, analyzing the U.S. healthcare market and developing strategic approaches for the company. Since 2003, she is the owner and President of Healthcare Reimbursement Strategy Consulting, which evaluates healthcare policy, coverage, coding, and payment issues, and the impact of reimbursement on the healthcare market. She serves the Association for the Advancement of Wound Care (AAWC) as the Chair of the Regulatory Committee (2008 onward) and a member of the AAWC Quality Measure Chore Force and Finance Committees. Since 2012, she serves on the Board of the Alliance for Wound Care Stakeholders.

References

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865623/

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