CPT® Process - How a Code Becomes a Code
Why is CPT Important?
The CPT coding system offers doctors across the country a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency. For more than four decades, physicians and other healthcare professionals have relied on CPT to communicate with colleagues, patients, hospitals and insurers about the procedures they have performed.
The CPT Editorial Panel is tasked with ensuring that CPT codes remain up to date and reflect the latest medical care provided to patients. In order to do this, the Panel maintains an open process and convenes meetings three times per year to solicit the direct input of practicing physicians, medical device manufacturers, developers of the latest diagnostic tests, and advisors from over 100 societies representing physicians and other qualified healthcare professionals.
The information on this page will provide you with an overview of the background of CPT and the process of taking a code change request from application to submission for Panel consideration.
Current Procedural Terminology (CPT®), Fourth Edition, is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians and other healthcare providers, patients, and third parties.
CPT descriptive terms and identifying codes currently serve a wide variety of important functions. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT is also used for administrative management purposes such as claims processing and developing guidelines for medical care review.
The uniform language is also applicable to medical education and research by providing a useful basis for local, regional, and national utilization comparisons.
The American Medical Association (AMA) first developed and published CPT in 1966. The first edition helped encourage the use of standard terms and descriptors to document procedures in the medical record; helped communicate accurate information on procedures and services to agencies concerned with insurance claims; provided the basis for a computer oriented system to evaluate operative procedures; and contributed basic information for actuarial and statistical purposes.
The first edition of CPT contained primarily surgical procedures, with limited sections on medicine, radiology, and laboratory procedures. The second edition was published in 1970 and presented an expanded system of terms and codes to designate diagnostic and therapeutic procedures in surgery, medicine, and the specialties. At that time, a five-digit coding system was introduced, replacing the former four-digit classification. Another significant change was a listing of procedures relating to internal medicine.
In the mid to late 1970s, the third and fourth editions of CPT were introduced. The fourth edition, published in 1977, represented significant updates in medical technology, and a system of periodic updating was introduced to keep pace with the rapidly changing medical environment. In 1983 CPT was adopted as part of the Centers for Medicare and Medicaid Services (CMS), formerly Health Care Financing Administration's (HCFA), Healthcare Common Procedure Coding System (HCPCS). With this adoption, CMS mandated the use of HCPCS to report services for Part B of the Medicare Program. In October 1986, CMS also required state Medicaid agencies to use HCPCS in the Medicaid Management Information System. In July 1987, as part of the Omnibus Budget Reconciliation Act, CMS mandated the use of CPT for reporting outpatient hospital surgical procedures.
Today, in addition to use in federal programs (Medicare and Medicaid), CPT is used extensively throughout the United States as the preferred system of coding and describing health care services.
The Administrative Simplification Section of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the Department of Health and Human Services to name national standards for electronic transaction of health care information. This includes transactions and code sets, national provider identifier, national employer identifier, security and privacy. The Final Rule for transactions and code sets was issued on August 17, 2000. The rule names CPT (including codes and modifiers) and HCPCS as the procedure code set for:
- Physician services.
- Physical and occupational therapy services.
- Radiological procedures.
- Clinical laboratory tests.
- Other medical diagnostic procedures.
- Hearing and vision services.
- Transportation services including ambulance.
The Final Rule also named ICD-9-CM volumes 1 and 2 as the code set for diagnosis codes, ICD-9-CM volume 3 for inpatient hospital services, CDT for dental services, and NDC codes for drugs.
All health care plans and providers who transmit information electronically were required to use established national standards by the end of the implementation period, October 16, 2003. In addition, all local codes were eliminated and national standard code sets were required for use after October 16, 2003.
The CPT Editorial Panel is responsible for maintaining the CPT code set. The Panel is authorized by the AMA Board of Trustees to revise, update, or modify CPT codes, descriptors, rules and guidelines. The Panel is comprised of 17 members. Of these, 11 are physicians nominated by the National Medical Specialty Societies and approved by the AMA Board of Trustees. One of the 11 is reserved for expertise in performance measurement. One physician is nominated from each of the following: the Blue Cross and Blue Shield Association, America's Health Insurance Plans, the American Hospital Association, and the Centers for Medicare and Medicaid Services (CMS). The remaining two seats on the CPT Editorial Panel are reserved for members of the CPT Health Care Professionals Advisory Committee.
Five members of the Editorial Panel serve as the Panel's Executive Committee. The Executive Committee includes the Editorial Panel chairman, co-chairman and three panel members-at-large, as elected by the entire panel. One of the three members-at-large of the executive committee must be a third-party payer representative.
Supporting the CPT Editorial Panel in its work is a larger body of CPT advisors, the CPT Advisory Committee. The members of this committee are primarily physicians nominated by the national medical specialty societies represented in the AMA House of Delegates. Currently, the Advisory Committee is limited to national medical specialty societies seated in the AMA House of Delegates and to the AMA Health Care Professionals Advisory Committee (HCPAC), organizations representing limited-license practitioners and other allied health professionals. Additionally, a group of individuals, the Performance Measures Advisory Group (PMAG), who represent various organizations concerned with performance measures, also provides expertise.
The Advisory Committees' primary objectives are to:
- serve as a resource to the CPT Editorial Panel by giving advice on procedure coding and appropriate nomenclature as relevant to the member's specialty;
- provide documentation to staff and the CPT Editorial Panel regarding the medical appropriateness of various medical and surgical procedures under consideration for inclusion in CPT;
- suggest revisions to CPT. The Advisory Committee meets annually at the CPT Fall meeting to discuss items of mutual concern and to keep abreast of current issues in coding and nomenclature;
- assist in the review and further development of relevant coding issues and in the preparation of technical education material and articles pertaining to CPT; and
- promote and educate its membership on the use and benefits of CPT.
Over the course of more than four decades, not a single taxpayer dime has been spent to develop or maintain the CPT code set. The CPT code set is completed annually without cost to the U.S. government, and countless hours are spent to ensure that the CPT codes accurately reflect the medical care provided to patients.
Specific procedures exist for addressing requests to revise CPT, such as adding or deleting a code or modifying existing nomenclature.
Medical specialty societies, individual physicians, hospitals, third-party payers and other interested parties may submit applications for changes to CPT for consideration by the Editorial Panel. The AMA’s CPT staff reviews all requests to revise CPT including applications for new and revised codes. If AMA staff determines that the Panel has already addressed the question, staff informs the requestor of the Panel's coding recommendation. However, if staff determines that the request presents a new issue or significant new information on an item that the Panel reviewed previously, the application is referred to members of the CPT Advisory Committee for evaluation and commentary. Applications that have not received any CPT Advisor support will be presented to the CPT Editorial Panel for discussion and possible decision unless withdrawn by the applicant. Applicants will be notified if their applications have received no CPT Advisor support approximately 14 days prior to each meeting of the CPT Editorial Panel meeting. Applicants have the ability to withdraw their applications up until the agenda item is called at the meeting—thereafter the CPT Editorial Panel has jurisdiction over the agenda item.
The CPT Editorial Panel meets three times each year. AMA staff prepares agenda materials for each CPT Editorial Panel meeting. Panel members receive agenda material at least 30 days in advance of each meeting, allowing them time to review the material, review CPT Advisor comments and confer with experts on each subject, as appropriate. The Panel addresses nearly 350 major topics a year, which typically involve more than 3,000 votes on individual items.
A multi-step process naturally means that deadlines are very important. The deadlines for submitting code change applications and for compilation of CPT Advisors’ comments are based on a schedule which allows at least three months of preparation and processing time before the issue is ready for review by the CPT Editorial Panel. The initial step, which includes AMA staff and CPT Advisor review, is completed when all appropriate CPT Advisors have been contacted and have responded, and all information requested of an applicant has been provided to AMA staff.
Following review and compilation of CPT Advisors’ comments, AMA staff prepares an agenda item that includes the application, compiled CPT Advisor comments and a ballot for decision by the CPT Editorial Panel. Once the Panel has taken an action and preliminarily approved the minutes of the meeting, AMA staff informs the applicant of the outcome.
The Panel actions on an agenda item can result in one of four outcomes:
- addition of a new code or revision of existing nomenclature, in which case the change would appear in a forthcoming volume of CPT;
- referral to a workgroup for further study;
- postponement to a future meeting (to allow submittal of additional information in a new application); or
- rejection of the item.
Applicants or other interested parties who wish to seek reconsideration of the Panel's decision should refer to the process described on the AMA/CPT website.
All complete CPT code change applications are reviewed and evaluated by the 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 appliction, including all necessary supporting documents;
- Adherence to all posted deadlines;
- Cooperation with requests from the 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:
- 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.
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 of 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);
- 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.
CPT Category II codes are supplemental tracking codes that can be used for performance measurement. The use of the tracking codes for performance measurement will decrease the need for record abstraction and chart review, and thereby minimize administrative burdens on physicians and other health care professionals. These codes are intended to facilitate data collection about quality of care by coding certain services and/or test results that support performance measures and that have been agreed upon as contributing to good patient care. Some codes in this category may relate to compliance by the health care professional with state or federal law.
The use of these codes is optional. The codes are not required for correct coding and may not be used as a substitute for Category I codes.
Services/procedures or test results described in this category make use of alpha characters as the 5th character in the string (i.e., 4 digits followed by an alpha character). These digits are not intended to reflect the placement of the code in the regular (Category I) part of the CPT code set. Also, these codes describe components that are typically included in an evaluation and management service or test results that are part of the laboratory test/procedure. Consequently, they do not have a relative value associated with them.
Tracking codes for performance measurement are released three times yearly following approval of the Panel minutes after each Editorial Panel meeting (March 15th, July 15th, and November 15th) on the AMA CPT Category II website (http://www.ama-assn.org/go/cpt-cat2), and published annually in the CPT book as part of the general CPT code set.
Tracking codes are reviewed by the Performance Measures Advisory Group (PMAG), an advisory body to the CPT Editorial Panel and the CPT Health Care Professionals Advisory Committee (CPT/HCPAC). The PMAG is comprised of performance measurement experts representing the Agency of Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA), and the Physician Consortium for Performance Improvement. The PMAG may seek additional expertise and/or input from other national health care organizations as necessary for the development of tracking codes. These may include national medical specialty societies, other national health care professional associations, accrediting bodies, and federal regulatory agencies. PMAG recommendations are then forwarded to the CPT/HCPAC Advisory Committee just as requests for Category I CPT codes are reviewed. The PMAG is interested in:
- measurements that have been developed and tested by a national organization;
- evidence-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 used by large segments of the health care industry
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 CPT Editorial Panel; OR
- There is a) at least one Institutional Review Board approved 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.
CPT's effectiveness depends on constant updating to reflect changes in medical practice. Suggestions from physicians, medical specialty societies, state medical associations, and those who deal regularly with health care information are the only way to ensure that CPT reflects current practice. Accordingly, the AMA welcomes correspondence, inquiries, and suggestions concerning old and new procedures. Coding change request forms are available through the AMA and are required to initiate a review of a proposed coding change by the CPT Advisory Committee. These forms play a vital role in maintaining and increasing the efficiency of the CPT process.The next items are questions that should be answered before submitting suggestions for changes to CPT:
Generally, all the components of a procedure are included in the code for a procedure. For example, CPT code 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s), includes all of the components listed if they are performed at that operative session. Requesting a new code for total abdominal hysterectomy (corpus and cervix), with removal of tubes would be an example of fragmentation. However, if the physician intended to perform an abdominal hysterectomy with bilateral salpingo-oophorectomy but only removed both tubes (bilateral salpingectomy), CPT code 58700 Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) would be used to report this component of what is normally considered an integral part of a total service.
To summarize, if there are several components of a procedure that are usually performed as part of that procedure, a separate code is not generally assigned for each component, unless the component is performed alone. The separate procedure is indicated after that procedure.
In the example above, creating a code for total abdominal hysterectomy (corpus and cervix) with removal of tubes would fragment an existing procedure that already includes these components when they are performed as well as additional components (bilateral removal of ovaries).
Certain procedures describe only a portion of a surgery performed, such as resection of a lesion or tumor. The procedure that is performed after the resection will vary, depending on the individual patient and the extent of the disease or other complicating factors. This may require reporting two or more procedure codes to completely indicate the services/procedures performed to treat one problem.
For example, CPT code 42120 Resection of palate or extensive resection of lesion, identifies the surgical resection performed, but the repair of the defect will depend on the exact location of the lesion and the extent of the resection. An adjacent tissue transfer or a free skin graft may be performed, or a flap or surgical obturator may be used to repair the defect. The CPT Editorial Panel does not try to create codes which cover all possible combinations for the removal/resection of the lesion and the subsequent repair. It is expected that two or more codes will be used to report these procedures.
CPT lists descriptive terms and identifying codes used to report medical services and procedures. Review the proposed coding change/addition. What does the actual service involve? If the only service provided is the review information stored in computers and does not require performance of a test, CPT code 99090 Analysis of clinical data stored in computers (eg, ECG, blood pressures, hematologic data) can be used to report this analysis. While many sophisticated devices and equipment to perform procedures or provide services exist, CPT's intent is to list those services/procedures in which actual work performance or direct supervision is required from a physician or practitioner. The device/equipment they use is not listed in the code.
related to performance of procedure/service already included in CPT?
A modifier indicates that a service or procedure performed has been altered by some specific circumstance but not changed in its definition or code.
For example, if a physician performed a cholecystectomy on a patient who was morbidly obese, a cholecystectomy would still be reported. The fact that the physician spent two additional hours performing the surgery (because of the complexity of the procedure due to the obesity) does not change the actual procedure being reported. The physician may add modifier 22 to the reported cholecystectomy code. The physician should attach a copy of the operative report or a narrative note to the claim form when submitting it to the third-party payer, indicating the additional work involved to perform this particular procedure.
If the answers to the preceding questions suggest a new descriptor/code is needed, you may submit your proposal by completing a coding change request form, which will require the following information:
- a complete description of the procedure/service (eg, describe in detail the skill and time involved. If this is a surgical procedure, include an operative report that describes the procedure in detail);
- a clinical vignette which describes the typical patient and work provided by the physician/practitioner;
- the diagnosis of patients for whom this procedure/service would be performed;
- a copy(s) of peer reviewed articles published in US journals indicating the safety and effectiveness of the procedure, as well as the frequency with which the procedure is performed and/or estimation of its projected performance;
- a copy(s) of additional published literature which you feel further explains your request (eg, practice parameters/guidelines or policy statements on a particular procedure/service); and
- evidence of FDA approval of the drug or device used in the procedure/service if required.
Refer to the current section of the CPT to which you believe the proposed code/coding change relates. In your letter, provide the rationale to answer the following questions:
- Why aren't the existing codes adequate? (Be very specific.)
What specific descriptors are you proposing? (Suggest wording for what you are proposing as well as placement of the proposed code(s) within the existing code range.)
- Can any existing codes be changed to include these new procedures without significantly affecting the extent of the services? (If not, give reasons why the existing codes are deficient.)
- Give specific rationale for each code you are proposing, including a full explanation on how each proposed code differs from existing CPT codes.
- If a code is recommended for deletion, how should the service then be coded?
- How long (ie, number of years) has this procedure/service been provided for patients?
- What is the frequency in which a physician or other practitioner might perform the procedure/service?
- What is the typical site where this procedure is performed (eg, office, hospital, nursing facility, ambulatory or other outpatient care setting, patient's home)?
- Does the procedure/service involve the use of a drug or device that requires FDA approval?
Simply completing the information requested does not ensure that the CPT Editorial Panel will adopt your suggestion. Since the initial AMA staff and CPT Advisory Committee review process takes several weeks, you may contact AMA staff for any questions related to the deadline dates and schedule which apply to a particular CPT year cycle. CPT schedule information is also available on the CPT Editorial Panel Process Calendar (http://www.ama-assn.org/go/cpt-calendar). Following preliminary finalization of the Panel minutes, AMA staff will notify you of the action that the CPT Editorial Panel has taken on your application.
As the designated standard for the electronic reporting of physician and other health care professional services under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), CPT codes are updated annually and effective for use on January 1 of each year. The AMA prepares each annual update so that the new CPT books are available in the fall of each year preceding their effective date to allow for implementation.
Category I vaccine product codes, Molecular Pathology and Category III codes are typically "early released" for reporting either January 1st or July 1st of a given CPT cycle. In order to comply with HIPAA requirements, the effective dates for these codes have been altered to become effective six months subsequent to the date of release following code set updates. As a result, codes released on January 1st are effective July 1st, allowing 6 months for implementation, and codes released on July 1st are effective January 1st.
Category II codes are typically "early released" for reporting three times yearly (March 15th, July 15th, and November 15th) following approval of the Panel minutes after each Editorial Panel meeting. The effective dates for these codes have also been altered to become effective three months subsequent to the date of release following code set updates. For example, codes released on July 15th are effective October 15th, allowing 3 months for implementation.
The American Medical Association has many CPT related products. The AMA Store has a full listing of the CPT related products. You may also call (800) 621-8335 to ask for a copy of the catalog to be sent to you.