CPT® Coding Change Request Instructions
Thank you for your request for additions, revisions, or deletions to CPT®. It is important that you carefully read and answer all of the questions on the enclosed proposed change form. You may attach a hard copy of supplemental literature and information to support your request.
In preparation for completing the Coding Change Form, you should familiarize yourself with the introductory material and guidelines included within Current Procedural Terminology, Fourth Edition (CPT®) and the CPT conventions (i.e. semicolon, the indent, “separate procedure,” cross-references). Please review the index of CPT before concluding that there are no codes to use for a particular procedure, as they might be located in a section that you are not familiar with. Also, please consider, to the degree possible, what other section of CPT might be affected when making changes in a particular area and list the complete family of codes related to your request. This will allow the CPT Advisory Committee and Editorial Panel to perform a full review on the impact of your request on related codes.
In your proposal please clearly identify the items that you are proposing be added, modified or deleted. Use the conventional techniques of strikeouts for deletions, underlining for additions and/or modifications, bullets () for new codes, and triangles () for revised codes.
Example of how your proposed change should appear
33860 Ascending aorta graft, with cardiopulmonary bypass,& without valve suspension
338X1 with coronary reconstruction
338X2 with aortic root replacement using composite prosthesis and coronary reconstruction
Development of Clinical Vignette
A clinical vignette is required for each code change request (except for minor editorial changes). A clinical vignette describes the typical patient who would receive the procedure(s)/service(s) including diagnosis and relevant conditions. A sample format to use in developing a clinical vignette for a procedure and/or service is included with this material. This same vignette is used during the development of work values by the AMA/Specialty Society RVS Update Committee (RUC).
The Coding Change Request Form has been revised to include coding changes for three different categories of CPT codes. The intent of each of the three categories of codes is different and it is important to understand the uses for each.
Category I CPT Codes
Category I CPT codes describe a procedure or service identified with a five-digit CPT code and descriptor nomenclature. The inclusion of a descriptor and its associated specific five-digit identifying code number in this category of CPT codes is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations.
Application Submission Requirements
All CPT code change applications are reviewed and evaluated by CPT staff, the CPT/HCPAC Advisory Committee, and the CPT Editorial Panel. Strict conformance with the following is required for review of a code change application:
- Submission of a complete application, including all necessary supporting documents;
- Adherence to all posted deadlines;
- Cooperation with requests from CPT staff and/or Editorial Panel members for clarification and information; and
- Compliance with CPT Lobbying Policy.
General Criteria for Category I and Category III Codes
All Category I or Category III code change applications must satisfy each of the following criteria:
- The proposed descriptor is unique, well-defined, and describes a procedure or service which is clearly identified and distinguished from existing procedures and services already in CPT.
- The descriptor structure, guidelines and instructions are consistent with current Editorial Panel standards for maintenance of the code set.
- The proposed descriptor for the procedure or service is neither a fragmentation of an existing procedure or service nor currently reportable as a complete service by one or more existing codes (with the exclusion of unlisted codes). However, procedures and services frequently performed together may require new or revised codes.
- The structure and content of the proposed code descriptor accurately reflects the procedure or service as typically performed. If always or frequently performed with one or more other procedures or services, the descriptor structure and content will reflect the typical combination or complete procedure or service.
- The descriptor for the procedure or service is not proposed as a means to report extraordinary circumstances related to the performance of a procedure or service already described in the CPT code set; and
- The procedure or service satisfies the category-specific criteria set forth below.
Category Specific Requirements
Category I Criteria
A proposal for a new or revised Category I code must satisfy all of the following criteria:
- All devices and drugs necessary for performance of the procedure or service have received FDA clearance or approval when such is required for performance of the procedure or service.
- The procedure or service is performed by many physicians or other qualified health care professionals across the United States.
- The procedure or service is performed with frequency consistent with the intended clinical use (i.e., a service for a common condition should have high volume, whereas a service commonly performed for a rare condition may have low volume).
- The procedure or service is consistent with current medical practice.
- The clinical efficacy of the procedure or service is documented in literature that meets the requirements set forth in the CPT code change application.
Note: Applications requesting establishment of CPT codes for vaccine products may be considered prior to submission of the Biologic License Application (BLA) to the FDA, but will not be considered until evidence substantiating completion of Phase III Clinical Trials and review of unblinded data is submitted to AMA.
Category II CPT Codes – Performance Measurement
Category II CPT codes are intended to facilitate data collection by coding certain services and/or test results that are agreed upon as contributing to positive health outcomes and quality patient care. This category of CPT codes is a set of optional tracking codes for performance measurement. These codes may be services that are typically included in an Evaluation and Management (E/M) service or other component part of a service and are not appropriate for Category I CPT codes. The use of tracking codes for performance measures will decrease the need for record abstraction and chart review, thus minimizing administrative burdens on physicians and survey costs for health plans.
CPT Performance Measurement codes are assigned an alphanumeric identifier with a letter in the last field (eg, 1234F). These codes are located in the Category II section of CPT, following the Medicine section. Introductory language in this code section explains the purpose of these codes. The use of these codes is optional, and not required for correct coding.
Requests for Category II CPT codes will be reviewed by the CPT/HCPAC Advisory Committee just as requests for Category I CPT codes are reviewed. In developing new and revised performance measurement codes the Advisory Committee and the Editorial Panel will be assisted by a Performance Measurement Advisory Group. The Advisory Group considers requests for codes for:
- measurements that were developed and tested by a national organization;
- evidenced 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 being used by large segments of the health care industry across the country.
These codes are not referred to the RUC for valuation because no RVUs are assigned to them. Since some of the Category II codes are services embedded within E/M codes, the aggregate service is already valued.
CPT codes for performance measures are released annually in print through the usual CPT publication process for that CPT cycle and in regular updates to the CPT Web site.
Category III CPT Codes – Emerging Technology
This section of CPT contains a temporary set of tracking codes for new and emerging technologies. Category III CPT codes are intended to facilitate data collection on and assessment of new services and procedures. These codes are intended to be used for data collection purposes to substantiate widespread usage or in the FDA approval process. As such, the Category III CPT codes may not conform to the usual CPT code requirements that.
Category III Critieria
The following criteria are used by the CPT/HCPAC Advisory Committee and the CPT Editorial Panel for evaluating Category III code applications:
- The procedure or service is currently or recently performed in humans; AND
At least one of the following additional criteria has been met:
- The application is supported by at least one CPT or HCPAC advisor representing practitioners who would use this procedure or service; OR
- The actual or potential clinical efficacy of the specific procedure or service is supported by peer reviewed literature which is available in English for examination by the Editorial Panel; OR
- There is a) at least one Institutional Review Board approved a protocol of a study of the procedure or service being performed, b) a description of a current and ongoing United States trial outlining the efficacy of the procedure or service, or c) other evidence of evolving clinical utilization.
The service/procedure must have relevance for research, either ongoing or planned.
These codes will be assigned an alphanumeric identifier with a letter in the last field (eg, 1234T). These codes are located in a separate section of CPT, following the Category II code section. Introductory language for this code section explains the purpose of these 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 not accepted by the Editorial Panel because the proposal was incomplete, more information is needed or the Advisory Committee did not support the proposal.
Once approved by the Editorial Panel, the newly added Category III CPT codes are made available on a semi-annual (twice a year, July 1, January 1) basis via electronic distribution on the AMA/CPT Web site. The full set of Category III codes is then included in the next published edition for that CPT cycle.
Category III CPT codes are not referred to the AMA /Specialty RVS Update Committee (RUC) for valuation because no relative value units (RVUs) are assigned to these codes.
These codes will be archived after five years if the code has not been accepted for placement in the Category I section of CPT, unless demonstrated that a Category III code is still needed. This set of codes is numbered chronologically, and the numbers are not reused.
Code change process
After completion and submission of the coding change request form, AMA staff reviews each form for completeness and then forwards the form to the CPT Advisory Committee for a detailed review of the substance of the proposal. Depending on the results of the CPT Advisory Committee review, requests may then be forwarded to the CPT Editorial Panel for a final decision. Coding change request forms for Category II CPT codes are first reviewed by the Performance Measurement Advisory Group. These proposals must receive a 2/3rd majority opinion at the advisory group level before they are passed on to the CPT Advisory Committee. Requests may then be forwarded to the CPT Editorial Panel for a final decision. We recommend that you refer to the enclosed CPT/RUC calendar of upcoming meetings for a list of important deadline dates for submission of CPT code changes. Also, please read the brochures provided on the CPT and RUC (AMA/Specialty Society RVS Update Committee) processes for a more complete discussion. Due to the nature of CPT Advisory Committee reviews, receipt of your request prior to a deadline date does not guarantee immediate inclusion in the next upcoming CPT Editorial Panel meeting.
Enclosures: Proposed coding change request form
CPT informational folder (with CPT process and RUC process brochures)
If you have any questions concerning the above requirements, please consult with AMA staff prior to the submission of your proposal.
An incomplete application may delay processing of your request.
All incomplete applications will be returned.
AMA CPT Editorial Research and Development: (312) 464-5486
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