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The CPT® Code Process

Read about the process for changes to the CPT® codes and the role of the CPT Advisory Committee.
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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 composed 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:

  • Blue Cross and Blue Shield Association
  • America's Health Insurance Plans
  • American Hospital Association
  • CMS

The remaining 2 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 3 panel members-at-large, as elected by the entire panel. One of the 3 members-at-large of the executive committee must be a third-party payer representative.

The Role of the CPT Advisory Committee

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.

The advisory committee's 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 the CPT code set.
  • Suggest revisions to the CPT code set. The advisory committee meets annually at the CPT February 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 the CPT code set.
  • Promote and educate its membership on the use and benefits of the CPT code set.

Over the course of more than 4 decades, no taxpayer money 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.

Requests for Changes to CPT

Specific procedures for changes to the codes and criteria for each code category exist for addressing requests to revise CPT, such as adding or deleting a code or modifying existing nomenclature. Make sure to submit the appropriate application form with the request.

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.

The Role of the CPT Advisors

The CPT Editorial Panel meets 3 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 multistep 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 3 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 1 of 4 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)
  • Rejection of the item

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.

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 document (PDF).

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 application, 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.
  • Compliance with CPT Lobbying Policy, Confidentiality Agreement and Conflict of Interest Disclosure Requirements (DocuSign® electronic signature required).

Criteria for CPT Codes

Before submitting changes/additions to CPT codes, make sure applications meet general and specific criteria for Category I, II and III codes. Proposals must satisfy all criteria listed to be considered.

CPT Codes Implementation Schedule

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 Jan. 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 Tier 2 codes, Administrative MAAA codes and Category III codes are typically "early released" for reporting either Jan. 1 or July 1 of a given CPT cycle. In order to comply with HIPAA requirements, the effective dates for these codes have been altered to become effective 6 months subsequent to the date of release following code set updates. As a result, codes released on Jan. 1 are effective July 1, allowing 6 months for implementation, and codes released on July 1 are effective Jan. 1.

Category II codes are typically "early released" for reporting 3 times yearly (March 15, July 15 and Nov. 15) following approval of the panel minutes after each editorial panel meeting. The effective dates for these codes have also been altered to become effective 3 months subsequent to the date of release following code set updates. For example, codes released on July 15 are effective Oct. 15, allowing 3 months for implementation.

 

CPT Process Resources

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