CPT Application Frequently Asked Questions
CPT® Process - How a Code Becomes a Code on the AMA website contains an overview description of the CPT process.
When your application has been received, AMA/CPT staff review the application to determine whether it addresses a new issue, or presents significant new information about an item that the Panel reviewed previously. Staff also looks at responses to each question in the application to verify that each question has been completed. If this is not the case, the application is returned to the applicant for completion within a defined timeframe (e.g., 5 business days). Applications for multiple codes require a separate response following each question for each code. This is especially important when completing the portion of the application that asks for the vignette and description of the service, since each code requires a "typical patient" vignette and is intended to represent a distinct service.
Upon receipt of the completed application, the application is published to the secure CPT website for review by the CPT Advisory Committee and the Health Care Professionals Advisory Committee (together the CPT HCPAC/Advisory Committee or "CPT Advisors"). The CPT Advisors are composed of representatives of national medical specialty societies seated in the AMA House of Delegates and the Health Care Professionals Advisory Committee (HCPAC). The HCPAC is composed of representatives of organizations representing qualified non-physician health care professionals.
Prior to submitting an application, applicants are encouraged to work with the relevant specialties whose members would most logically provide the requested procedure/service. Applicants who wish to contact the specialty societies prior to submitting an application should contact the departments of coding and reimbursement for the national specialty societies listed in the front matter of the CPT code book. Similarly, those who wish to contact the organizations representing qualified non-physician health care professionals that belong to the HCPAC should contact the departments of coding and reimbursement for these organizations that are listed in the front matter of the CPT code book.
Only the CPT Editorial Panel has the final authority to decide on code category assignment. You are allowed in the application to request the final assignment of the CPT Code category to the codes you seek. The assignment of the code category is based upon Panel evaluation relative to the code criteria outlined in the online CPT process booklet.
For Category I/Category III codes, the following criteria are used to assist the CPT Advisors and Panel in determination of the code category assignment.
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
A. 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.
B. Category III Criteria
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 CPT Advisors submit their opinions to the CPT Editorial Panel based on the information contained in the application and clinical literature you have submitted with your application. The questions in the application require you to supply the details related to the relevant procedure(s) to assist the CPT Advisors and the Editorial Panel in:
- determination of whether existing codes are currently reported for this service,
- identification of the physicians and other qualified health care professionals who commonly provide the requested service,
- determination if other services are provided at the same time as your described service,
- determination of how the procedural components of your service are depicted in the description,
- determination of whether the literature submitted to support your service addresses the efficacy of the described service (as opposed to description of a related service),
- whether all of the components of the service have FDA approval when required.
Panel deliberation takes place three times yearly at the CPT Editorial Panel meetings, as described in the CPT/RUC calendar that can be found on the CPT website. Panel review of the code change applications begins one month prior to each Panel meeting.
The Editorial Panel can accept as written, accept with modification (e.g., altered descriptor wording, different code category), reject or postpone the request for a new or revised code. You will receive an email notice from AMA staff three weeks after the conclusion of the meeting to notify you of the outcome of the Panel's consideration.
If accepted, the wording of the code descriptor and any relevant coding instructions is included in the notice of acceptance. However, you may not release this information to any other parties since future Panel actions may impact your code(s).
If your code application is rejected or approved in a code category different than you suggested, you are offered the option to submit a request for reconsideration within ten days of receipt of the notice.
If your application is postponed, you will receive an email notice from AMA staff three weeks after the conclusion of the meeting, with specific instructions for the required information for re-presentation of your application.
Changes in codes are frequently caused by the evolution over time of incremental changes in the technique, components, or technologies used with the service or procedure. These changes may not substantively disrupt the basic procedure, may lead to improved patient outcomes and may become the standard of care.
When brought to the attention of the Panel, significant changes to the service may result in Panel determination that technological enhancements of the service have substantially altered the procedure originally described by the code. The Panel may request submission of a code change application (whether by revision or deletion of the existing code[s] and/or addition of a new code[s]), to facilitate review of evidence and input through the multi-stakeholder CPT process and comparison with the Category I/Category III criteria and ultimate Panel determination of the most accurate service description for the new/different service.
When existing Category I codes are revised to reflect the evolution of the service, the Panel determines at that time whether the revisions are substantial or editorial. Category I codes that are substantially revised are referred for review by the RUC after each Panel meeting, for the determination of the valuation recommendations for the code. Category I codes that are revised so extensively that the meaning of the code is changed may be deleted and assigned a new CPT code number with the revised text.
If an applicant believes an action of the Editorial Panel was in error, the applicant may seek reconsideration. Requests for reconsideration must be in writing and received within fourteen (14) days of receipt of notice of this Panel action. The request must address the reasons and/or instructions given in the notice for the Panel's action. Requests for reconsideration are referred to the CPT Executive Committee for an initial determination followed by referral (with or without recommendation) to the Editorial Panel for reconsideration. If a request is rejected upon reconsideration, a second request for reconsideration will not be entertained until one year after the first reconsideration by the Executive Committee, unless new information directly relevant to the Panel's original consideration of the request becomes available in the interim. This second request must respond to the Panel's original rationale.
Once the application has been submitted to the Editorial Panel, all actions related to the code application are under the authority of the Editorial Panel. Although the applicant is asked to provide specific language for the new code descriptor(s), you should not expect that Editorial Panel acceptance of your application will result in addition of the exact description you provide in the application. A part of the Editorial Panel's consideration of the code change application is deciding on a specific option from a number of descriptor options resulting from the review by the AMA staff, the CPT Advisors, and consideration by the CPT Editorial Panel. An important objective of the Panel is to ensure that the final descriptor adheres to CPT conventions, is clear and unambiguous, does not include proprietary references and is not seen as an endorsement of a particular device or service.
You may withdraw your application until the time that you begin your oral presentation to the Editorial Panel. At that time the discussion falls under the authority of the Editorial Panel and the request may not be withdrawn. If the Panel deems that additional information or evaluation is warranted, it may be postponed until time certain (a specific future CPT meeting) or time uncertain.
In assisting you for preparation of your presentation to the Editorial Panel, AMA staff will provide you with the agenda item for your application ten days prior to the meeting. This agenda item contains information not included in your application, including all alternate ballots and options provided for the Panel's consideration as a part of the CPT Advisors review, and a summary of all comments from the CPT Advisors related to your request.
Your presentation to the Editorial Panel begins with a brief introduction of yourself to the Panel and disclosure of any potential conflict of interest. Following initiation of discussion by Panel members specifically assigned to discuss your Code Change Application, they or the Chairman may ask for a brief overview of the procedure or service for which you are requesting a CPT code. You should be prepared to respond to questions posed by the Editorial Panel related to your application. Please prepare to answer questions regarding the purpose of the requested code(s), why existing codes are not sufficient, and the specific nature of the service(s) or procedure(s) based on the clinical vignette(s) submitted with your application. You should familiarize yourself with the content of the CPT code set and its conventions (e.g., use of symbols and modifiers, structure and format of code descriptors), and the guidelines in the introduction of the code book.
You may have more than one presenter for Panel discussion of your application. For the most effective presentation to the Panel, the presenter(s) should be a physician or other qualified healthcare professional who performs the service or procedure. All presenter(s) should be prepared to respond to the Panel's questions related to the details of providing the procedure/service.
Provision of additional handout materials to the Panel during the meeting is not allowed. The Panel cannot perform a reasonable review of these materials on short notice while giving full consideration to your application. Audio-visual aids (slides, videotapes, etc.) cannot be used. Formal presentation of your written material is not necessary or allowed since the Panel received the agenda materials well in advance of the meeting. Your application for a code change is expected to stand by itself with the supporting peer-reviewed literature to provide the Panel with the information needed to make a determination on your application. Prior to Panel discussion, all presenters are required to provide signed statements of confidentiality and disclosure of potential conflict of interest. These forms are provided by AMA staff prior to the meeting.
The Lobbying Statement is intended to protect specialty societies and their CPT Advisors, and the members of the CPT Editorial Panel, from inappropriate lobbying regarding code change applications. “Lobbying” is defined as unsolicited communications of any kind made at any time (including side bar discussions during Editorial Panel meetings) for the purpose of attempting to improperly influence either (1) CPT/HCPAC Advisors’ or their societies’ evaluation of or comments upon a code change request or (2) voting by members of the Editorial Panel on a code change request. Any communication that can reasonably be interpreted as coercion, intimidation or harassment is strictly prohibited. Please see the AMA statement on lobbying on the AMA Web site.
This prohibition is balanced against the legitimate need for code change applicants to receive valuable feedback from specialty society experts, which helps assure that code change applications are complete, coherent and consistent with current medical practice and can be dealt with efficiently by the CPT Editorial Panel. Thus, sending information to a specialty society to inform the society of the code change application and seeking evaluation of (or assistance with) the application does not violate the Lobbying Statement, even if it includes a request to support the code change application.
The Panel also invites public statements at the Editorial Panel meetings and in certain workgroups. These are not considered “unsolicited comments” but must be made in manner that would not otherwise violate the prohibition or are disparaging to individuals or their organizations.
The prohibition of lobbying is intended to preclude threatening, coercive or harassing communications or activities—or repeated conduct of this sort, especially if the recipient has made clear further contacts are unwelcome. For example, if a society or its CPT Advisor indicates that there is no interest in receiving further information from the applicant, then communications from the applicant and its representatives should cease.
Your application for a code change and peer-reviewed literature is expected to provide the Panel with all of the information needed to make a determination on your application. If an applicant or other interested party wishes the CPT/HCPAC Advisors or the Editorial Panel to consider additional information after a code change application has been submitted to the AMA, that information must be submitted to AMA's CPT staff. Such information will be handled through the CPT process.
Those who wish to contact the specialty societies for assistance in construction of a code change application related to that specialty should contact the departments of coding and reimbursement for the national specialty societies listed in the front matter of the CPT code book. Similarly, those who wish to contact the organizations representing qualified non-physician health care professionals that belong to the HCPAC should contact the departments of coding and reimbursement for these organizations that are listed in the front matter of the CPT code book.
If an applicant or other interested party wishes the CPT Advisors or the Editorial Panel to consider additional information, that information must be submitted to AMA's CPT staff for distribution to the entire roster of CPT Advisors and to the Editorial Panel. This information must be provided to CPT staff no later than two months prior to the Editorial Panel meeting. You are not permitted to provide information directly to Editorial Panel members or CPT Advisors. Such contacts or providing information is considered improper "Lobbying" and is prohibited.
Revision of your application after the deadline date is strongly discouraged as this may cause confusion during CPT Advisors' review. Occasionally, during AMA staff review of your application and prior to CPT Advisors' review, deficiencies in your application may be identified. You will be instructed to provide additional information within the timeframe defined by AMA staff. This is the only instance that revised applications are appropriate.
Following finalization of the Panel minutes you will receive an email notice from AMA staff, approximately three weeks after the conclusion of the meeting, to inform you of the Panel actions related to your application.
Discussions of an agenda item often take place at multiple times throughout the meeting. For this reason, a specific time or day cannot be provided with certainty for any item. Presenters should plan to be present for the entire meeting schedule.
The CPT Editorial Panel agenda is available on the AMA CPT public website. While the monitoring of discussion of issues at the meeting is open to all, the actual meeting agenda materials are considered to be confidential and are not available for review. Public attendance at a meeting requires that you sign a confidentiality agreement.
Attendees can request recognition at the floor microphones at the Panel meeting to provide comments on agenda items under discussion. Speakers who wish to comment must submit a signed conflict of interest statement prior to speaking. When you are recognized, the Chairman will ask that you introduce yourself, identify any organization that you represent and declare any potential conflict of interest. AMA staff will provide the necessary documents for signature by prospective participants upon request.
The sharing of information about the CPT Editorial Panel meetings is restricted by the terms of the confidentiality agreement you have signed. Panel decisions are posted following each meeting in the CPT Editorial Panel Summary of Actions, published on the AMA web site CPT home page. Disclosure of Panel actions and deliberations is limited to the information contained in the Summary of Actions.
Specialty society members, staff and any others who are involved in surveys for the AMA/Specialty Society RVS Update Committee for approved Category I codes are also notified of Panel outcomes through the "Level of Interest" process. Immediately following CPT Editorial Panel meetings, applicable codes go through the RVS Update Process (RUC) for survey and review, for inclusion in the list of RUC relative value recommendations to CMS each year. For a complete account of the RUC, see The RVS Update Process.
New and revised code descriptions may be further refined prior to publication each year. For this reason code numbers are not assigned, nor exact wording finalized, until just prior to publication of the annual CPT code set.
Premature release of coding information other than the Panel Summary of Actions is prohibited under the CPT Confidentiality Agreement.