Before applying for a new Current Procedural Terminology (CPT®) code, it’s important to determine whether the innovation needs a CPT code.
Generally, if the innovation involves a new clinical service, procedure, or technology that healthcare professionals will perform and bill for, a CPT code is part of that pathway. If the tool, device or app does not change clinical workflow or is not independently billable, a CPT code may not be required.
Reasons why you might want your procedure or service to be described by a CPT code
- You are developing a medical procedure or service to be delivered in the United States.
- You anticipate coverage by public and/or private health insurance. (Note: Assignment of a CPT code to a procedure or service does not guarantee coverage or payment, and it does not establish a relative value. Coverage, payment, and reimbursement are determined by Medicare, Medicaid, private insurers, and other payers under their own policies).
- You anticipate use of real-world data related to your medical procedure or service through claims databases and/or electronic health records.
Reasons why your procedure or service might not need to be described by a CPT code
- You are developing a disposable supply that does not have differentiated physician work, such as durable medical equipment (DME), direct-to-consumer (DTC) technologies, or general wellness or capital equipment. (A HCPCS Level II code for the supply might be more appropriate than a new procedure in the CPT code set.)
- You are utilizing a payment model that does not involve reimbursement from insurance plans or depend on procedure-level billing. (In these scenarios, having a tracking code may still be useful, so it is important to understand how your services will be reported or otherwise identified.)
Review the decision tree to help determine if you need a CPT code.
Disclaimer: This information does not supersede specific coding guidance published in the CPT codebook, which is subject to change and further modification by the CPT Editorial Panel. Establishment of a CPT code does not imply approval, endorsement, or sponsorship of the medical procedure or service by the AMA. A CPT code does not guarantee coverage, reimbursement, or payment. The AMA disclaims responsibility for any errors or omissions and for any consequences attributable to or related to any use, reliance, or interpretation of the information herein.
