Proposed Changes to CPT Category I and III Code Criteria

The current Category I code criteria were first published as a November 1991 CPT Assistant article, in response to sweeping changes taking place at that time in the CPT process (eg, opening of the meetings to CPT Advisors, introduction of a new Evaluation and Management code set, introduction of the AMA’s Relative Update Valuation Committee) following discussion and approval by the Editorial Panel.

The Category III code criteria were added in May 2003 when the Panel accepted establishment of a formalized mechanism for Panel review and determination of the appropriate establishment of Category III codes when evaluating Category III code requests.

Since that time, the services being performed by physicians and other qualified healthcare professionals have dramatically changed, and the demands for CPT to be responsive to the changing healthcare environment have increased substantially.  To keep pace with this change, the Panel is continuously looking at ways to improve the CPT process.

At the October 12-15, 2011 meeting, the Panel discussed and approved that a process should be undertaken to revise and update the Category I/Category III code criteria. Following the October meeting, two sets of revisions to the criteria have been extensively vetted by the Panel and the Executive Committee.

The attached document contains proposed updates/revisions to the Category I/Category III code criteria by the Panel. 

The document proposes revisions of the text in the CPT Introduction (CPT Professional Edition pages x [Introductory text] and xi [Requests to Update the CPT Nomenclature]). Further revisions to the Introduction include (1) a new initial set of administrative criteria (Application Submission Requirements/ General Criteria for Category I and Category III Codes), which apply to all Category I and Category III codes and (2) specific Category I and Category III criteria that have been revised to reflect more relevant standards for review of code applications.

New sections of text will appear as underlined. Strikethroughs and underlines denote revisions of (1) the current CPT code book Introduction on pages x and xi and (2) the current Category I/Category III criteria. Areas that are highlighted (general and specific criteria) denote text that is new to the Introduction to CPT.

In these proposed criteria, it should be noted that staff action of “termination of process” (removal of item from agenda when specialty support is lacking) is not included in the code criteria. Specialty society support for an application has never been a requirement listed in the published code criteria.

The following are the major points and reasons for change:

• Creation of consistent language regarding criteria in a primary source, the CPT code book
• Clarify that Advisor support is not a Category I criteria that must be met
• Add a requirement that descriptor, guideline and instruction text must be sufficiently clear and consistent with CPT standards as many code proposals require postponement or revision for this reason, yet it is not an explicit criteria.
• Address component coding and combined services standards
• Provide examples of “many practitioners in clinical practice in multiple locations” as a relative state, so as to further define the intent of the criteria.

The Panel has proposed that approval of the new criteria will take place following implementation of a process to obtain comment from the industry stakeholders and other members of the public on the CPT public site. The public comment period closes on Friday, April 20^th. The comments that have been received will be submitted to the Panel for consideration by the Panel at the May 2012 meeting.

If you have any questions, please contact Marie Mindeman, Director, CPT Coding and Regulatory Affairs at marie.mindeman@ama-assn.org.

Please provide your comments on the attached form.