CPT^®: An Open System That Describes All That You Do

Article Outline

• Abstract
• Introduction
• The Formative Years (1966-1980): A Brief History
• The Current Procedural Terminology Editorial Panel
• The Current Procedural Terminology Advisory Committee
• Opening the Current Procedural Terminology Process
• Confidentiality and Disclosure
• The Health Insurance Portability and Accountability Act and the American Medical Association’s CPT-5 Project
  • Eliminating Ambiguity
  • Ability to Adapt to New Procedures
  • Codes for Reporting Performance Measures
  • Improvement in Computer Search Capability
• HHS Decision
• How Radiologists and Their Practices Can Stay Current
• Summary
• References
• Copyright

The American Medical Association, with the cooperation of multiple major medical specialty societies, including the ACR, responded in 1966 to the need for a complete coding system for describing medical procedures and services with the first publication of Current Procedural Terminology (CPT^®). This system, now CPT^® IV, forms the basis of reporting of virtually all inpatient and outpatient services performed by physicians and nonphysician health care providers as well as facilities. This coding system and its maintenance process have evolved in complexity and sophistication, particularly in the past decade, such that it is now integral to all facets of health care, including tracking new and investigational procedures and reporting and monitoring performance measures (read “pay for performance”), in addition to its long-standing use for reporting for reimbursement. To paraphrase a recent automobile commercial, “This is not your father’s CPT.” The author describes the development of CPT as it exists today, examining the forces that molded its current form, the input opportunities available to medical specialty societies and others, the ever increasing transparency of the CPT maintenance process, and the availability of resources allowing all to stay current. Understanding this system, critical to the practice of all of medicine, including radiology, will aid all health care providers in maintaining the quality, efficiency, and accuracy of their practices’ business operations as well as assist them in a world of increasingly complex reporting requirements.

Key Words: CPT, coding, performance measures

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Introduction 

In 1966, Medicare had just been established by Congress, medical care was growing in sophistication and volume, and computers were rapidly becoming the cornerstone of financial transactions and record keeping. The need for an alphanumeric coding system to describe medical procedures was clear. In response, the American Medical Association (AMA), with input from representatives of a number of major national medical specialty societies, developed the first version of Current Procedural Terminology (CPT^®). Over the next 3 decades, this system was expanded to accommodate the ever increasing number and complexity of medical services and procedures, the addition of nonphysician health care providers, and the incredible new technological developments within the health care system.

In 1996, the Health Insurance Portability and Accountability Act included a requirement that the US Department of Health and Human Services (HHS) name national standards, including specifying code sets, for electronic transactions of health care information. This prompted the AMA to perform a complete multiyear analysis of the strengths and weaknesses of CPT, which resulted in numerous significant structural changes, all while continuing to update the code set. Over the past decade, the implementation of these changes has expanded CPT beyond just procedure and service reporting into tracking the development of new services and procedures, as well as facilitating the reporting of clinical care performance measures being developed by many national organizations and evaluated by virtually all third-party payers.

There are many stakeholders in this process, including medical specialty societies, payers, and vendors developing new medical technology, in addition to all individual health care providers. As a result, particularly during this past decade, there has also been a demand to “open” the CPT maintenance process, increasing the opportunity of all these stakeholders to participate in the process of CPT code establishment.

In this article, I describe the development of CPT, with an emphasis on recent modifications, examining the forces that molded its current form, the input opportunities available to medical specialty societies and others, the ever increasing transparency of the CPT maintenance process, and the availability of resources allowing all to stay current with this critical code set, CPT modifiers, and the guidelines for their use.

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The Formative Years (1966-1980): A Brief History 

The first edition of CPT (1966) primarily described surgical procedures, with only small sections allotted for medicine, radiology, and pathology. Initially, it was devised as a 4-digit coding system. This initial foray was to determine if a set of “standard terms and descriptors to document procedures in the medical record” [1] would be useful for both health insurance agencies and those doing statistical health care research. By 1970, it was clear that this system had merit, but also limitations, and the second edition (CPT II) was published, expanding the individual codes to 5 digits and the content to include the full spectrum of then-available diagnostic and therapeutic procedures in “surgery, medicine, and the specialties” [1].

Over the next several years, modifications and updates were made, resulting in CPT III and CPT IV (introduced in 1977). With these changes, it became apparent that the scope of this system and the increased specialization of medicine required a sophisticated update and review process, with input from all medical specialty societies and major stakeholders. The increasing importance of CPT was not lost on those involved in organized medicine, and the desire for widespread input was reflected in the action taken by the AMA House of Delegates (HOD) in 1980 and reaffirmed in 1990 and 2000 in house resolution H-70.998 (on the revision of CPT) [2]:

Our AMA continues to support taking all appropriate measures, including meetings if necessary, to ensure that no CPT updating process proceed without providing for input from knowledgeable physicians, including a cross section of affected and related specialties, to allow these physicians to carefully review all changes suggested for inclusion in CPT prior to their acceptance.

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The Current Procedural Terminology Editorial Panel 

On the basis of the identified need for systematic review and widespread input, the maintenance of CPT was delegated to the CPT Editorial Panel. To remain efficient, the Panel is kept at a reasonable size, currently 17 members. The constitution of this Panel has been a point of discussion over the years but has been modified only slightly in response to specific identified needs. It is constructed with representation from physicians, nonphysician health care providers, payers, and the American Hospital Association. These seats are designated as follows:

Note that with only 11 nondesignated physician seats, all specialties cannot have continuous presence on the Panel. To afford the opportunity for all specialties to participate, 4 of these seats are “rotating,” eligible for just one 4-year term, while the other 7 “full” seats are eligible for two, 4-year terms. It is important to understand that the 11 physician Panel members are not “representatives” of any given specialty. Rather, they are appointed to provide objective review of all proposals, regardless of their source. These members leave their specialty hats at the door. In response to a prior attempt to expand the Panel composition to have “representation” from all specialties (similar to the AMA’s Relative Value System Update Committee [RUC]), the AMA HOD responded with resolution H-70.925 (on editorial Panel representation) in 2002 as follows [3]:

(1) The CPT Editorial Panel shall be kept at a size compatible with its functioning as an efficient and effective editorial board and should not be subject to the requirement of formal slotted seats for individual specialty societies. (2) While the role of the CPT Advisory Committee as clinical and technical experts to the CPT Editorial Panel is important, necessary, and currently of satisfactory composition, the need to expand as the practice of medicine changes or the scope of the CPT code set changes should be regularly evaluated.

Recognizing that the most common use of CPT codes is for processing claims for reimbursement, the Panel does all that is possible to separate proper coding from reimbursement issues. Although this had historically been the case, the need for this separation was addressed by the AMA HOD in 1993, soon after the RUC was created to deal with valuation, and reaffirmed in resolution H-70.966 (on the CPT process) in 2005 [4]:

It is the policy of the AMA that the CPT Editorial Panel continue its policy of not making coding decisions that are influenced by economic or budgetary considerations. It is the responsibility of the AMA/Specialty Society RVS Update Committee to consider implementation issues such as economic factors when it recommends work values for new and revised CPT codes.

Finally, the function of the Panel was recently addressed by the AMA HOD in resolution H-70.919 (on the use of the CPT Editorial Panel process) in 2006 [5]:

Our AMA reinforces that the CPT Editorial Panel is the proper forum for addressing CPT code set maintenance issues and all interested stakeholders should avail themselves of the well-established and documented CPT Editorial Panel process for the development of new and revised CPT codes, descriptors, guidelines, parenthetic statements and modifiers.

The Panel currently meets 3 times a year to evaluate all “code change proposals” (additions, revisions, and deletions), totaling approximately 350 proposals and 3,000 votes per year.

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The Current Procedural Terminology Advisory Committee 

As reinforced in the resolutions cited above, it was and remains clearly necessary to have widespread, organized input from the numerous medical specialty societies in support of the editorial process. This was accomplished through the establishment of the CPT Advisory Committee. This committee of more than 100 individuals is made up of representatives of all national medical specialty societies that have seats in the AMA HOD as well as “organizations representing limited-license practitioners and other allied health professionals” [1]. The ACR has a CPT advisor, as do 10 other radiology-related specialty societies.

The responsibilities of those advisors are multiple [1]:

Clearly, each of these advisors will have support from staff members and probably coding committees within their respective organizations.

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Opening the Current Procedural Terminology Process 

As any CPT advisor from the 1980s will attest, the CPT Editorial Panel at that time was a strictly “closed-door” operation. Originally, any code change requests were submitted with supporting documentation, and the Panel would decide on the basis of that information, or any supplementary information requested, whether any code change was necessary. Beginning in the late 1980s, the individuals responsible for change requests were allowed to enter the room to be available for any questions from the Panel but were excused before any Panel deliberations. They were informed of the results of their applications several weeks after the meeting. There was a clear need to be more inclusive and open the process. This was recognized by the AMA HOD in resolution H-70.973 (on the CPT Editorial Panel and process) in 1992 [6]:

The AMA will continue (1) to work to improve the CPT process by encouraging specialty societies to participate fully in the CPT process; (2) to enhance communications with specialty societies concerning the CPT process and subsequent appeals process; and (3) to assist specialty societies, as requested, in the education of their members concerning CPT coding issues.

In response, the Panel opened the doors, allowing all advisors and their specialty staff members to attend the full meeting, including deliberations on code change proposals. Requestors are given seats at the Panel table during the discussion of their proposals and respond to questions from Panel members. In addition, members of the Advisory Committee or their staff members with interest in the proposals can make comments or pose questions. This allows for a thorough and complete discussion of each proposal, with consideration of all perspectives.

Additional steps in opening the process came with the development of the AMA’s CPT Web site (http://www.ama-assn.org/ama/pub/category/3113.html) and the admission of anyone interested in attending a Panel meeting. This does allow press representatives to attend, but all are required to sign confidentiality agreements prohibiting estimates or projections of vote outcomes. Votes on the issues presented are done electronically and remain confidential, revealed only to Panel members during executive sessions, and are not considered final until the minutes of the specific meetings have been approved by the full Panel. Because an appeals process exists for those who would like reconsideration of a Panel decision (obviously most common when a proposal is rejected), Panel action is not considered final until it is published in the CPT book of that cycle.

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Confidentiality and Disclosure 

Recognizing that decisions made by the CPT Editorial Panel can have ramifications well beyond the health care community (eg, vendors’ stocks on Wall Street), all those attending Panel meetings are routinely instructed not to disclose any perceived “results” of the meeting to anyone beyond those in their specialty organizations who need to know for subsequent RUC valuation processes, and so on. The code change proposal form has specific questions that must be answered by requestors regarding any financial conflicts of interest, and presenters are specifically requested during meetings to disclose any potential conflicts at the beginning of consideration of their proposals. This has become increasingly important as more proposals are brought forward by industry representatives. In addition, all Panel members are required to sign disclosure agreements at each meeting of any potentially significant financial relationships and disclose any such relationships before discussion of specific proposals.

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The Health Insurance Portability and Accountability Act and the American Medical Association’s CPT-5 Project 

Multiple prior decisions have been made by Congress and the CMS (and its predecessor, the Health Care Financing Administration) that have been critical to CPT remaining at the hub of health care reimbursement, including the following:

Perhaps the most important, however, is the 2000 designation of CPT as the national coding standard for reporting physician and other health care professional services and procedures. As described earlier, the administration simplification section of the Health Insurance Portability and Accountability Act in 1996 specifically required that the secretary of HHS “adopt standards for financial and administrative transactions, and data elements for those transactions, to enable those transactions to be exchanged electronically” [8]. During the process of selecting those standards, a set of “principles” [8] were developed against which any standard would be judged. Current Procedural Terminology, as it existed at that time, was felt to have several deficiencies relative to those principles. This prompted the AMA HOD to pass resolution H-70.971, affirming CPT as the exclusive system for coding claims [9]:

The AMA (1) affirms the use of CPT codes as the exclusive system of describing physician services on claims submitted to Medicare and all other private and public payers; and (2) authorizes its Board of Trustees to take all necessary actions to assure the continued use of CPT as the sole method for coding physician services on claims submitted to Medicare.

The AMA Board of Trustees then established the CPT-5 Project. Involving all medical specialties and nonphysician provider groups, as well as multiple outside consultants, the intent of this effort was a comprehensive evaluation of CPT and the implementation of any necessary revisions to make it in compliance with all the “principles” necessary to be considered as a national standard code set by HHS.

Overseen by the Project Advisory Group, 6 workgroups were established, each of which made recommendations to the Project Advisory Group. They met numerous times over the next 2 years. More than 100 specific recommendations were made and considered, well beyond the scope of this article, but several are key to the recent evolution of CPT and affect how it is used in all medical practice. Although the changes were not felt sufficient to change the name from CPT IV to CPT V, per the name of the project, they are nonetheless significant.

Eliminating Ambiguity 

One of the core principles cited was that the national standard code set should “be precise and unambiguous” [8]. Thus, a fundamental effort of the CPT-5 Project was to review all existing codes looking for any source of ambiguity. This meant eliminating or revising numerous codes, developing internally consistent nomenclature, and a simple but very significant change in the general instructions for use of CPT codes. Before 2002, the general introductory language instructed users to report the code that “most accurately” described the service provided. In 2002, this instruction was changed, eliminating the word most, thus mandating that users “select the name of the procedure or service that accurately identifies the service performed” [10]. It goes on to state, “Do not select a CPT code that merely approximates the service provided” [10].

Ability to Adapt to New Procedures 

Another fundamental principle was that the national standard code set should “incorporate flexibility to adapt more easily to changes in the health care infrastructure (such as new services, organizations and provider types) and information technology” [8]. Current Procedural Terminology had no capability to track new developing procedures and technologies that did not qualify for assignment of a “prime-time,” Category I code. As a result, a whole new category of CPT codes, Category III codes, was developed. These are “temporary codes for emerging technology, services and procedures” that “allow data collection for these services/procedures” [10]. These codes are designated by 4 numbers followed by “T” and are listed in a separate section of the CPT book. The requirements for US Food and Drug Administration approval, widespread geographic use, and abundant peer-reviewed literature used for Category I code assignment are not used for Category III codes. Rather, the following guidelines have been established by the CPT Editorial Panel as required information to determine if a new procedure can be considered for a Category III code:

The Panel, presented with a new procedure code proposal, now has the option to assign a Category III code that specifically identifies that procedure, allowing providers and payers to discuss coverage and payment and track utilization. In addition, medical specialty societies, providers, or vendors involved in the development of such procedures now have a mechanism for specific code assignment for procedures or services that don’t meet Category I requirements, thus avoiding the use of nonspecific and potentially ambiguous “unlisted procedure” CPT codes. Unlike the Category I codes, which are issued once a year, and effective January 1, Category III codes are released on the AMA’s CPT Web site every 6 months (January 1 and July1), because they do not go through the RUC valuation process.

Codes for Reporting Performance Measures 

Much has been written in this and other journals about the ever increasing scrutiny of medical practice and performance measures developed by such national organizations as the National Committee for Quality Assurance, the National Quality Forum, the National Patient Safety Foundation, and the AMA’s Physician Consortium for Performance Improvement. For CPT to serve effectively as a national standard code set, the Editorial Panel and staff felt it imperative that a code category be developed to assist in the reporting of these quality measures. The result is the recently implemented Category II CPT codes.

Although the Editorial Panel and the Advisory Committee do not develop the actual measures, they use the existing mechanisms and experience of code review to ensure that these “performance measurement” [10] codes are in a format that can be understood and reported by all who use CPT. Although the reporting of these codes is voluntary, there is little doubt that with such programs as the CMS Physician Quality Reporting Initiative, which increases Medicare reimbursement from July1, 2007, through December 31, 2007, for those practices that report compliance with such measures, these will become an integral part of reporting of medical care. The number of Category II codes is growing rapidly, and their use will certainly increase as well. They are listed in a separate section of the CPT book and can be found on the AMA’s CPT Web site. All practices should be evaluating their office computer systems to ensure they are capable of capturing and reporting these new codes.

Improvement in Computer Search Capability 

An additional principle for a national standard code set is that it should “keep data collection and paperwork burdens on users as low as feasible” [8]. Because of CPT’s development over 40 years and its current use predominantly in hard-copy form, CPT Category I codes needed some rewriting and reorganization to allow for electronic searches and distribution formats. Phrases common in CPT descriptors, such as “and/or” and “with or without” limit both precision and computer search capabilities. With the help of an outside consultant, numerous changes have been incorporated into CPT, such as the recent renumbering and relocation of multiple radiology codes to new subsections. This has been done while maintaining the basic structure of the major sections.

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HHS Decision 

On the basis of these improvements and the wide use of and support for CPT throughout the health care industry, the CMS final rule issued August 17, 2000, named CPT as a national standard code set for

It continues as a national standard, with expanding roles as described above.

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How Radiologists and Their Practices Can Stay Current 

Clearly, CPT is a dynamic and ever changing code set. Radiologists and their business office personnel responsible for “accurately” using CPT cannot just be casually familiar with its use, particularly during these times of compliance scrutiny. Fortunately, radiologists have a number of valuable resources to help them keep current and out of trouble. The ACR provides all members with coding advice in the ACR Bulletin and the ACR Coding Source,™ both free ACR member benefits, as well as periodic articles in this journal. In addition, multiple coding guides have been published by the ACR solely or in cooperation with major radiology related societies, including those on interventional radiology [11], ultrasound [12], radiation oncology [13], and nuclear medicine [14]. The AMA publishes CPT Assistant, a publication covering all of CPT, and coproduces Radiology Clinical Examples with the ACR, each of which is reviewed by their respective editorial boards and are available by subscription.

Just receiving these publications is not sufficient. They must be understood and their guidance incorporated into daily practice, which requires a significant time commitment by both physicians and staff members. The Radiology Business Management Association provides extensive educational materials to its members and is a significant resource. Finally, the Radiology Coding Certification Board provides radiology and radiation oncology practice coders with the opportunity to achieve certified status, demonstrating their knowledge of all critical coding systems, including CPT.

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Summary 

Over the past 40 years, CPT has existed as an effective system for reporting and recording the delivery of medical procedures and services, expanding to include those performed not only by physicians but by all health care providers. In the past decade, in response to the needs of the health care industry as a whole, the scope of the CPT code set has expanded dramatically. In addition, its maintenance has evolved from a process with relatively limited access and input to one that is open, transparent, and inclusive. It is now not only important for reporting the full spectrum of accepted medical procedures that you and your partners perform but also critical for new and emerging procedures and services as well as demonstrating compliance with performance measures in the current environment of increasing accountability. Diligence in staying current with this national standard code set is critical.

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References 

1. American Medical Association. CPT process. Chicago, Ill: American Medical Association; 2004;
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7. Thorwarth W. From concept to CPT code to compensation: how the system works. J Am Coll Radiol. 2004;1:48–53
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8. 45 CFR Part 142, Fed Reg p 25273.
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