Current Procedural Technology: History, Structure, Process & Controversies

Martin J. Citardi, MD
Professor & Chair

 

Every day, physicians rely upon Current Procedural Terminology (CPT) to report their services for payment by the Centers for Medicare & Medicaid Services (CMS) and other third-party payers. Increasingly, CPT coding captures quality and outcome measures — a feature that is likely to have increasing importance in the era of Pay for Performance (P4P) and the Physician Quality Reporting Initiative. Despite its near-ubiquity for reporting physician work, misconceptions about CPT are common. In fact, a recent on-line survey summarized considerable misconceptions about CPT.

CPT History

CPT is owned and maintained by American Medical Association, which has copyright protection on CPT. In 1966, the AMA published the first edition of CPT, which at that time focused on surgical procedures. The first edition sought to standardize terminology and reporting. The second edition, in 1970, expanded CPT’s scope. The third and fourth editions were released in the 1970’s. The fourth edition was a major update, and introduced a system for periodically monitoring and updating CPT. In 1983, the Health Care Financing Administration (HCFA), now CMS, adopted CPT for reporting of physician services for Medicare Part B Benefits. In 1987, HCFA also adopted CPT for reporting outpatient surgical procedures.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required that the Department of Health & Human Services develop standards for electronic data storage and transmission. Four yours later, the Department published the Final Rule, which selected CPT for reporting physician services (and other medical services) and International Classification of Diseases (9th revision, Clinical Modification), also known as ICD-9-CM for reporting diagnosis codes.

CPT Structure

CPT codes are divided into 3 categories:

  • Category I CPT codes are assigned to procedures that are deemed to be within the scope of medical practice across the US. In general, such codes report services whose effectiveness is well supported in the medical literature and whose constituent parts have received clearance from the US Food and Drug Administration (FDA). The Relative Value Scale (RVS) Update Committee (RUC) process assigns relative value units (RVUs) for all Category 1 CPT codes.
  • Category II CPT codes are tracking codes designed for the measurement of performance improvement. The concept is that the use of these codes should facilitate the administration of quality improvement projects by allowing for standardized reporting that captures the performance (or non-performance) of services designated as subject to process improvement efforts.
  • Category III CPT codes are temporary codes for new or emerging technology or procedures. Such codes are important for data collection and serve to support the inclusion (or exclusion) of new or emergency technology in standard medical practice. Category 3 CPT codes are not assigned a value through the RUC process.

CPT Process

The AMA CPT Editorial Panel maintains CPT. The panel consists of 11 physicians nominated by the National Medical Specialty Societies, one physician nominated by the Blue Cross and Blue Shield Association, one physician nominated by America’s Health Insurance Plans, one physician nominated by the American Hospital Association, and one physician nominated by CMS. The AMA Board of Directors approves all nominations. The CPT Health Care Professionals Advisory Committee sends two representatives.

The CPT Advisory Committee supports the CPT Editorial Panel, which consists of physicians nominated by national medical societies that are part of the AMA House of Delegates. The CPT Advisory Committee provides important information on specialty-specific issues and suggests CPT revisions. The Performance Measures Advisory Committee (PMAC), which focuses on performance metrics, also provides input. The AMA’s regular staff also provides an important role.

Proposals for a new code go through the following steps:

  • The specialty society develops the initial proposal. Typically, the specialty society will be most familiar with trends shaping a specific specialty. As a result, the specialty society can represent important trends driven by technology, changing practice, etc.
  • The AMA Staff reviews the code proposal. This preparatory step confirms that the issue has not been previously addressed and that all of the documentation is in place.
  • The CPT Specialty Advisory Panel then reviews the code proposal. All are given the opportunity to comment, and those comments are then shared with all participants in the process, but not with the general public.
  • The CPT Editorial Panel then reviews the code proposal at its regularly scheduled meeting. The group can approve the code, table the proposal, or reject the proposal.
  • Approved Category 1 codes are then submitted to the RUC for valuation.

CPT Category III Process

All CPT Category III codes are removed after 5 years from the time of publication. If the original requestors of the code want to continue use of the code, they must submit a proposal for continuing the code as a Category III code or promoting it to Category I status. Because it is difficult to imagine why the fate of an emerging technology would not be clear within 5 years, no Category III code has been renewed for a second 5-year term.

Category III codes are important for maintaining the integrity of the CPT process, since they permit a means to track the use of new technology, before such technology is widely adopted. The use of similar Category I codes for new technology is clearly discouraged by the CPT rules; in fact, the rules, in their strictest sense, actually prohibit this. The other alternative is the use of unlisted procedure Category I code, but when physicians do this, it becomes impossible to measure the actual usage of a specific technology. Thus, the preferred route for coding new technology is the development and application of a Category III code.

Summary

Physicians rely upon CPT codes, maintained by the AMA, to report services for payment. CPT has evolved since its introduction, and the AMA has a specific process for monitoring the integrity of CPT and adapting for changes in physician practice and medical technology. The AMA’s rules are quite specific, and over the long-run, physicians (and their patients) will be best served by following the recommendations of CPT process explicitly.