How CPT code set’s public process helps health innovation thrive

Andis Robeznieks , Senior News Writer

Often called “the language of medicine,” the Current Procedural Terminology (CPT®) code set is the foundation for how the provision of care is described and reported across the health care ecosystem. Representatives from medical specialty societies, health insurers, medical coders and government agencies are meeting this week in Chicago to facilitate the path between medical innovation, payment and physician adoption.

These experts are coming together to attend a meeting of the CPT Editorial Panel (the Panel), during which applications for updates to the CPT code set will be deliberated. The public agenda highlights the nearly 60 code change applications that were received for the Panel meeting, including the code(s) affected and a brief description of the request. 

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The CPT Editorial Panel is an independent body of 21 volunteer physicians and other qualified health care professionals (QHPs) appointed by the AMA Board of Trustees. Operating autonomously and prioritizing openness and transparency, the Panel collects broad input from stakeholders across the health care community to ensure CPT content reflects the coding and data-driven demands of a modern health care system. The Panel is supported by over 200 advisers who are nominated by specialty societies. The Centers for Medicare & Medicaid Services (CMS) has an advisory role on the Panel, and representatives from the Food and Drug Administration and the Centers for Disease Control and Prevention were recently invited to the table.

“One of the most important things the AMA does is our work as a convener, and the CPT process and everything that rolls up through our health solutions team is an important example of that convening,” AMA President Jesse M. Ehrenfeld, MD, MPH, said during a panel session hosted by the AMA at the ViVE health technology conference in Los Angeles.

Further highlighting the importance of the CPT Editorial Panel process, Lori Prestesater, the AMA’s senior vice president for health solutions, moderated the AMA’s session at ViVE and noted that the CPT codes are defined through a process that plays out at three public, hybrid meetings every year. She added that 450 people attended the February meeting in San Diego, with many more watching online.

The CPT process is open and transparent, Prestesater said. Anyone can attend a Panel meeting and anyone can submit a code change application.

Providing needed evidence

Once a code change application is received, the Panel members review all applications against certain criteria, such as having “sufficient published literature to document the value and the medical appropriateness of whatever the procedure is that is being discussed,” said panelist Barbara Levy, MD, vice chair of the AMA CPT Editorial Panel and former chair of the AMA/Specialty Society RVS Update Committee (RUC).

“That level of evidence is really important because it also drives one very final important thing—which is physician adoption,” said Dr. Ehrenfeld, an anesthesiologist and health informaticist.

“The No. 1 most important driver is: Does the thing work and how does it work in my practice?” he added. “And that comes back to this question of evidence.”

The evidence also matters to payers who independently review the clinical evidence for each procedure or service that may receive coverage. This is why CPT codes, especially Category I codes, are often considered the first step on the path to payment and patient access.

“They look to the Panel to do that first level of filtering,” said Dr. Levy “And just because you get a code does not mean that either CMS or private payers will necessarily pay for the procedure. It's the first step. It's not the only step.”

Category III CPT codes, on the other hand, require less evidence for adoption and are generally used to track the use of new services or procedures.

“They're extremely helpful for new companies to be able to look at that adoption and to say, ‘Here's the evidence that lots of people are using this, and here's the patient population who feels this is really helpful,’” Dr. Levy said. “The codes provide the structure to be able to follow adoption of new technology over time.”

In addition to facilitating innovation of digital health tools, CPT codes are foundational to value-based care models because they account for the medical services and procedures that physicians and QHPs deliver to patients. By capturing and communicating data associated with cost and quality measures, digitally enabled care and emerging technologies, and coordination of patient care, the CPT code set supports new and novel care delivery models. 

Care-management CPT codes are another example of how the CPT code set reflects current clinical practice. “We realized that practices were devoting a huge amount of time and effort into managing patients when they weren't face to face,” Dr. Levy said. “We created a whole series of codes to talk about the transition from the hospital to home, to talk about chronic-care management, and to now talk about principal-care management, which are being used by nurse navigators in the [White House] Cancer Moonshot Initiative.”

Following the May meeting, the CPT Editorial Panel’s next meeting will be Sept. 19–21, in Albuquerque, New Mexico.