Martin J. Citardi, MD
Professor & Chair
Otorhinolaryngologists, like other physicians, consider innovation to be a core driver in improving the health of patients, since innovation offers the promise of new therapeutic alternatives. In the ideal world, innovation improves patient outcomes (and access) at lower cost, and physicians can evaluate each innovation without bias. In reality, the US healthcare system, which has a reputation for rapidly embracing new technology, is characterized by dysfunction in how it promotes, evaluates and adopts innovations:
Practicing surgeons, who employ new technology, often are frustrated by a reimbursement system that appears hostile to the introduction of new technology; this, of course, is further reflection of the dysfunctional state of American healthcare. In particular, surgeons will quickly point to the limitations of the American Medical Association’s Current Procedural Terminology (CPT) system, the foundation for reporting physician work for reimbursement, to demonstrate a critical obstacle. Unfortunately, this characterization of CPT is incomplete. While CPT is imperfect, it does offer pathways for introducing, evaluating and valuing new procedures and technology.
CPT codes are divided into 3 categories. Category I codes are the primary codes that are used for reporting accepted procedures and services, while category II codes are tracking codes for the measurement of process improvement. Category III codes are temporary codes explicitly designed for new and emerging technology.
Surgeons have 3 options for coding a procedure that is not explicitly covered by category I CPT codes:
How does the surgeon choose the optimal selection? The quick answer is that the first option is not the best choice.
CPT principles should guide the process:
Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. (from AMA Code Manager, 2011 Q-2 update)
Furthermore, CPT principles prohibit the application of a category I for an open procedure to the corresponding “endoscopic” procedure. This is an important concept, since many recent surgical interventions have included the application of endoscopic approaches for procedures that otherwise require incisions and “open” surgery.
Thus, the traditional surgeon preference for selecting an existing code is simply incorrect. The appropriate code will always be the category I unlisted procedure code—or a category III CPT code (if such a code exists).
Inappropriate usage of the category I code may be considered a fraudulent billing practice, even if the surgeon’s intent is to simply report work that he or she has been performed. Certainly, selection of the category I CPT code merely because it is more likely to be reimbursed is simply wrong. Furthermore, such inaccurate coding distorts code utilization reporting, which is an important part of the valuation process maintained by Center for Medicare Services (CMS).
The pathway for the development of a new code for new technology has the following milestones:
Surgeons need to understand the key characteristics for category I unlisted procedure codes:
Similarly, surgeons should be familiar with the features of category III codes:
Skeptics will quickly point out the pitfalls in following the CPT system’s approach for incorporating innovation, and they will have many valid points. But, these arguments are not a rationale for ignoring CPT’s ground rules. Over the long run, consistent application of CPT principles will help ensure an equitable and transparent approach for reporting physician work.