Why CPT is foundational in the transition to value-based care

Andis Robeznieks , Senior News Writer

For value-based health care to work, physician practices must be able to accurately describe the medical services and procedures they deliver, and this makes the Current Procedural Terminology (CPT®) code set an integral component of the movement toward value-based care.

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“Value-based care relies on a consistent nomenclature—one that’s been established for years and allows comparison of quality, and allows for improvement to be defined and proven over time,” said Ezequiel Silva III, MD, chair of the AMA/Specialty Society Relative Value Scale Update Committee (RUC).

Value-based care ties payment amounts for services provided to patients to the results that are delivered, such as outcomes, quality, equity and cost of care.

As payment models call for more risk sharing and accountability from physicians, the CPT code set takes on increased value of its own, said Dr. Silva, a San Antonio-based diagnostic and interventional radiologist.

“Our ability to adequately and accurately describe what we as physicians are doing Is as important as ever,” he said.

The past co-chair of the AMA Digital Medicine Payment Advisory Group, Dr. Silva noted that the CPT Editorial Panel has helped phase out fragmented care often associated with fee-for-service payment by establishing care management codes to address services that are typically performed after the face-to-face patient encounter is over. These include developing a care plan and coordinating with other professionals to execute that plan.

Dr. Silva spoke during a recent AMA webinar (available on demand with registration) that highlights how the CPT code set is foundational to innovative care models and payment reforms designed to help achieve high-quality and equitable patient care.

In addition to being used for billing, the CPT code set can provide data needed to design novel health care delivery models, and then assess the associated savings and quality improvement those models generate.

When new value-based care models emerge, the transparent and evidence-based CPT Editorial Panel process for developing new codes provides solutions that respond to the needs of physicians, health professionals, health systems, policymakers and payers. 

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Zach Hochstetler, the AMA’s director of editorial and regulatory services, also spoke during the webinar, and he highlighted how the Center for Medicare and Medicaid Innovation has set a goal for 100% of traditional Medicare beneficiaries to be getting value-based care from an accountable care organization (ACO) by 2030.

While there are different definitions of value-based care, Hochstetler noted that the “heart of the issue” is the concept of “patient-centered care.”

Hochstetler described the elements in the AMA’s framework for high-value care, which include:

  • A clear, shared vision with the patient at the center.
  • Leadership that promotes training with an emphasis on teamwork.
  • A robust IT infrastructure.
  • Broad access to care—especially for the sickest patients and those from minoritized communities.
  • Payment models that remove incentives for volume-based care.

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The AMA has developed an explainer on advancing value-based care with alternative payment models (PDF).

The AMA, the health insurer trade group AHIP, and the National Association of ACOs released a playbook to advance the adoption of value-based care arrangements in the private sector that could have a greater impact on the quality and equity of care and ease participation by fostering voluntary alignment of data-sharing practices.

The CPT 2024 Professional Edition codebook and other CPT resources are available from the AMA Storefront on Amazon. The book includes the more than 11,100 codes in the CPT code set and, for the first time, there are also consumer-friendly Spanish-language code descriptors.

Also available is an additional resource, CPT Changes 2024: An Insider’s View, designed to help the orderly annual transition to a newly modified CPT code set.

A CPT education section has also been created for the AMA Ed Hub™ online learning platform that contains a learning module series covering CPT coding basics.