The digital health environment is changing at a rapid clip with amazing advances in augmented intelligence (AI), telehealth and other tools for treating patients remotely or virtually leading the way.
One constant in this landscape has been the Current Procedural Terminology (CPT®) code set, which continues to evolve to keep pace with the innovations that promise to improve patient care while reducing burnout-inducing administrative burdens for physicians and their practices.
Dispelling myths about CPT codes
Speaking during a panel at the ViVE health IT conference in Los Angeles last year, Lori Prestesater, the AMA’s senior vice president of health solutions, started by “dispelling myths” that the CPT code set is merely a tool for fee-for-service payments and that the CPT Editorial Panel’s work is shrouded in secrecy.
“CPT codes are a path to payment, but they do not define payment—that's a common myth that people have,” Prestesater said.
“CPT codes are not just a mechanism for fee-for-service billing—they are a foundational way ... to define procedures and services provided by physicians and other qualified health professionals,” she added. “No matter what model of payment you're using, you still have to define and account for the care provided.”
As a uniform language of medicine, CPT codes are used to understand and communicate the story of a patient’s care across the health care ecosystem. While they do facilitate billing and physician payment, CPT codes also provide vital and actionable insights that support quality care measures, data interoperability and the adoption of emerging technologies and innovative care models that can improve patient care.
Another myth is that the AMA defines the codes. In fact, CPT codes are determined through a rigorous, open and transparent process that is led by the independent, 21-member CPT Editorial Panel. The physicians and other qualified health care professionals who are members of the CPT Editorial Panel are appointed by the AMA Board of Trustees and volunteer their clinical expertise and real-world experience to determine which codes are added, updated and removed from the CPT code set each year.
Their independent decisions are supported by input from over 200 advisers who are nominated by specialty societies. Importantly, input from individuals or entities who may be impacted by the CPT Editorial Panel’s decision on a code application that is pending before the Panel also informs the code development process. These interested parties are invited to review submission materials and make comments on specific agenda items through the Interested Party process.
As the largest association of physicians, the AMA convenes these experts and stakeholders from across the health care ecosystem so that diverse perspectives from industry, commercial health plans, federal agencies, physicians and other providers from more than 100 specialty organizations can inform the evolution of the CPT code set.
From AI implementation to digital health adoption and EHR usability, the AMA is fighting to make technology work for physicians, ensuring that it is an asset to doctors.
The code set continues to evolve
Noting that “the code set will continue to evolve,” Prestesater described how the CPT Editorial Panel added new codes in 2019 to support remote physiologic monitoring (RPM).
While CPT codes for RPM are now in common use, “at the time, those were innovative and forward looking,” she said. Early CPT codes for blood glucose monitoring and basic remote monitoring services paved the way for validating and capturing medical services that extended beyond the traditional office visit, especially for patients managing chronic conditions.
“Then, as the pandemic hit, we moved forward and digital care evolved, and we added a second set of codes in 2022 to support remote therapeutic monitoring [RTM],” Prestesater said.
The new codes “offered a broader reach” and “provided the foundation for reporting models of care that hadn't been implemented before.” Specifically, the RTM codes strengthened the CPT code set’s support for team-based care by enabling reporting for services managed by non-physician providers, such as physical therapists and respiratory therapists.
RPM tools assess data to appropriately manage diseases related to physiologic parameters, while RTM tools expand access to remote monitoring and monitoring of data related to signs, symptoms and functions of a therapeutic response. As adoption of new technologies increases, these codes will continue to evolve as the Panel considers new and refined use cases.
Citing the CPT taxonomy for classifying medical services powered by AI, which is often called “artificial intelligence,” Prestesater said that the AMA is working with several federal agencies, including the U.S. Food and Drug Administration, as well as industry stakeholders to provide standardized terminology for medical devices using AI.
“We need to really lean into innovation so that we can support whatever kind of models evolve that provide the right and best patient care,” she said.
CPT code set serves as information engine
CPT codes “play a foundational, continued role” in research and testing of new payment models (PDF), Prestesater said.
Fellow panelist, Lucia Savage, is chief privacy and regulatory officer for Omada Health, which offers a National Diabetes Prevention Program (National DPP) lifestyle-change program. Savage noted that Omada worked with the YMCA and others to submit an application to the CPT Editorial Panel for a new code for in-person and virtual National DPPs.
“We renewed the code in 2021 and, much to our surprise, many other people were also using this code at quite a high volume—so that was very gratifying,” Savage said, noting the important role the code played in advancing National DPPs.
“If we don't categorize the care properly under the CPT [code set], then we cannot analyze if the care is efficacious,” she explained.
The CPT code set provided the “information engine” that allowed for such an analysis, Savage said.
Collaboration, transparency and a focus on reflecting the coding and data-driven demands of a modern health care system are core principles of the CPT Editorial Panel process, Prestesater said.
To participate in this process, register to attend the next CPT Editorial Panel meeting, submit a code-change request or view actions that the CPT Editorial Panel has taken on code applications on the AMA website.
