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Category II Application

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Code Proposal Submission Instructions

Criteria for Submitting CPT Category II Code Proposals

  • Definition or purpose of the measure is consistent with its intended use (quality improvement and accountability, or solely quality improvement)
  • Aspect of care measured is substantially influenced by physician work (or work of other practitioner or entity for which the code may be relevant)
  • Reduces data collection burden on physicians (or other health practitioner or entity), reflects the work they perform, and is useful in physicians’ practice
  • Significant
    • Affects a large segment of health care community
    • Tied to health outcomes
    • Addresses clinical conditions of high prevalence, high costs, high risks
  • Evidence-based
    • Agreed upon
    • Definable
    • Measurable
  • Risk adjustment specifications and instructions for all outcome measures submitted or compelling evidence as to why risk adjustment is not relevant
  • Sufficiently detailed to make it useful for multiple purposes
  • Facilitates reporting of performance measure(s)
  • 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
  • Performance measure development process includes
    • Nationally recognized expert panel
    • Multidisciplinary
    • Vetting process

Definitions

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, Illinois 60611-5885
or email [email protected]

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