CPT® Category II Code Application
Instructions for code proposal submission
To submit a Category II code proposal to the PMAG, a careful review of the criteria and instructions for code submission is necessary. These instructions and criteria are described in the following:
The PMAG will consider code proposals submitted by national regulatory agencies, accrediting bodies, national professional and medical specialty societies, and other organizations. Code proposals must include documentation of the following:
- The purpose or definition of the measure is consistent with its intended use (e.g., quality improvement and accountability, or solely quality improvement);
- The aspect of care measured is substantially influenced by physician work (or work of other practitioner or entity for which the code may be relevant );
- The extent to which an evidence-based process was used for measures development;
- The extent to which a multidisciplinary review process was used to achieve consensus on measures among all constituents of the respective organizations, including internal and public comment processes;
- The extent to which measures were tested to confirm their validity and feasibility for data collection;
- Risk adjustment specifications and instructions are included for all outcome measures submitted or compelling evidence as to why risk adjustment is not relevant.
Criteria for submitting CPT® Category II code proposals:
A. Definition or purpose of the measure is consistent with its intended use (quality improvement and accountability, or solely quality improvement).
B. Aspect of care measured is substantially influenced by physician work (or work of other practitioner or entity for which the code may be relevant).
C. Reduces data collection burden on physicians (or other health practitioner or entity), reflects the work they perform, and is useful in physicians’ practice.
- Affects a large segment of health care community;
- Tied to health outcomes;
- Addresses clinical conditions of high prevalence, high costs, high risks;
- Agreed upon
F. Risk adjustment specifications and instructions for all outcome measures submitted or compelling evidence as to why risk adjustment is not relevant.
G. Sufficiently detailed to make it useful for multiple purposes.
H. Facilitates reporting of performance measure(s).
I. Inclusion of select patient history, testing (e.g., glycohemoglobin), other process measures, cognitive or procedure services within CPT, or physiologic measures (e.g., blood pressure) to support performance measurements.
J. Performance measure development process includes
- Nationally recognized expert panel
- Vetting process
Evidence-based practice is the integration of best research evidence with clinical expertise and patient values. Best research evidence refers to clinically relevant research, often from the basic health and medical sciences, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination); the power of prognostic markers; and the efficacy and safety of therapeutic rehabilitative, and preventive regimens. Clinical expertise means the ability to use clinical skills and past experience to rapidly identify each patient’s unique health state and diagnosis, individual risks and benefits of potential interventions, and personal values and expectations. Patient values refers to the unique preferences, concerns, and expectations that each patient brings to a clinical encounter and that must be integrated into clinical decisions if they are to serve the patient.
(Sackett, David L., Sharon E. Straus, W. Scott Richardson, et al. Evidence-Based Medicine: How to Practice & Teach EBM. 2nd edition. London, England: Churchill Livingstone, 2000.)
American Medical Association
Department of CPT Editorial Research and Development
330 N. Wabash Ave., Suite 39300
Chicago, IL 60611-5885