Transcript The CPT Process

Slides courtesy of: Richard W. Waguespack, MD, FACS
President Elect, AAO-HNS, Former CPT Editorial Panelist, CPT Advisor for the Triological
Society, Past Coordinator for Socioeconomic Affairs
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CPT Process
Members should understand:
• Manner by which CPT codes are created
and modified by the AMA
• Role of the AAO-HNS in the process
• Rudiments of bundling/code edits
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Current Procedural Terminology (CPT)
• The CPT code set has been developed, owned,
and maintained by AMA since 1966
• Is the national standard for electronic reporting
of health care information relating to physician
services, designated in the final rule for HIPAA
August 17, 2000
• The code set is maintained by the AMA CPT
Editorial Panel
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CPT Editorial Panel
• A total of 17 members – 11 physicians nominated by
Medical Societies plus one member each from:
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Blue Cross Blue Shield Association (BCBSA)
America’s Health Insurance Plans (AHIP)
American Hospital Association
Center for Medicare and Medicaid Services (CMS)
2 seats for members of Health Care Professional Advisory
Committee (HCPAC)
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CPT Editorial Panel
Executive Committee
• Editorial Panel Chair
• Co-Chair (serves as Chair of CPT Assistant
Editorial Board)
• Three Members-At-Large elected by entire
Panel (one must be a third-party payer
representative)
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CPT Advisors’ Role
CPT Advisors
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Support the Editorial Panel
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Nominated by national medical specialty societies that
are represented in the AMA House of Delegates and
AMA HCPAC
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Serve to give specialty-specific advice on coding and
nomenclature to Editorial Panel
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Give support to CPT staff, suggest revisions, review and
promote education of membership on use of CPT
•
Otolaryngology is represented by CPT Advisors from
the AAO-HNS, Triological Society, AAOA, and AAFPRS
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Types of Codes: Category I or III?
• Category I
• “Standard codes” but does not “guarantee”
carrier payment
• Higher threshold of usage, literature support,
standard of care
• Category III
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New technology and less literature support
May be used for tracking
FDA approval not required
Not valued by RUC but may be paid by carriers
• Unlisted and Category II codes
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CPT Development
Who can propose a new or request modifying an
existing CPT code?
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Individual person or institution
Specialty society
AMA CPT Editorial Panel members or staff
Medical device or drug company
Payer (commercial or governmental)
RUC (AMA Relative Value Update CMTE)
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The CPT Process
• Who can propose or modify a CPT
code?
• Individual person or institution
• Specialty society
• AMA CPT staff
• Medical device or drug company
• Payer, commercial or governmental
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The CPT Process
• Who can propose or modify a CPT
code?
• Individual person or institution
• Specialty society
• AMA CPT staff
• Medical device or drug company
• Payer, commercial or governmental
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Academy CPT Development
• Who as an Otolaryngologist can request a
new or revised CPT Code?
• Individual AAO-HNS member
• AAO-HNS standing committees, (e.g., Sleep Disorders, Rhinology
Paranasal Sinus)
• Medical device or drug company
• Subspecialty society, (e.g. AAOA (Serial Endpoint Titration Editorial
Change)) or others, (e.g. ASHA (cochlear implant programming
codes))
• Requests for code changes or revaluation must be
reviewed by the New Technology Pathway.
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Academy Review: New Technology Pathway
Academy Staff Intake of inquiry
Board
Updates
Health Policy Report/3P
Board representatives
3P (Physician Payment Policy Workgroup)
• Initial evaluation and communication to inquiring party, Academy staff, and 3P group – James C. Denneny, III,
M.D., Socioeconomic Coordinator.
• Assess appropriate coding based on committee input, CPT literature criteria, CPT code descriptors, and RUC
database descriptors
• Provide input and guidance for progression of -99 and Category III codes to Category I
•Lead the CPT process including creation and presentation of CCPs
•Lead the RUC process including creation, administration, and presentation of surveys
Medical Device and Drug Committee (MDDC)
• Assess safety, efficacy, and adoption of new
technology
CPT/RVU committee
• Assists 3P as needed with their processes
Academy Committees
• Provide information as needed to MDDC, CPT/RVU Committee, and 3P to make informed assessments
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CPT Development
If only the rest were this straight-forward...
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Bundling is a 4-Letter word
CPT is a reporting system; code edits and bundling
are reimbursement policies imposed by payers
Some edits are embedded in CPT
• CPT terminology “(separate procedure)”
• A separate procedure is one that should not be separately
reported if part of a larger service, eg, tracheostomy with total
laryngectomy
• Pay Close Attention to Parentheticals (“Do not report… or
Report… with….”)
• These parentheticals list codes that either should, or should not,
be reported with other codes.
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NCCI Edits
National Correct Coding Initiative (NCCI) for
Medicare
• Developed by Correct Coding Solutions LLC and adopted with approval
of CMS.
• Developed quarterly and specialty society input is sought (the Academy
is very active in this process).
• May be revised after issuance with clinical support.
• Often adopted by commercial carriers but beware of carriers that “cherry
pick” edits, global periods, etc.
• NCDs/LCDs (National/Local carrier determinations).
Contact Health Policy staff for assistance locating this information:
[email protected]
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