June 2001 Bulletin

AMA CPT panel creates 3 new classifications

Process for requesting new or revised CPT code remains the same

By Laura Neuchterlein

In recent years, the American Medical Association (AMA) CPT Editorial Panel has made several modifications to the CPT coding system and the process for obtaining new procedure codes. Among the most significant is the creation of three different classifications of CPT codes. The new classifications will appear in print for the first time in the 2002 CPT manual.

Category I codes are the traditional 5-digit CPT codes with accompanying descriptor. When developing a new or revised Category I code, the CPT Editorial Panel generally requires that the service/procedure has received FDA approval for the specific use of devices or drugs; that the service/procedure is performed across the country in a variety of locations; that many physicians or other health care professionals perform the service/procedure; and that the clinical efficacy of the service/procedure has been well documented in U.S. peer-review journals.

Category II codes are a set of optional tracking codes for performance measurement. They are intended to facilitate data collection by coding certain services and/or test results that are agreed upon as contributing to positive health outcomes and quality patient care. The codes might be services typically included in Evaluation and Management codes, or component parts of other services, and as such do not warrant a Category I code. It is hoped that the use of tracking codes for performance measures will decrease the need for chart review and result in reduced administrative burden on physicians and health plans.

Category II codes will be assigned a 5-digit alphanumeric code with the letter P at the end (e.g., 1234P). Beginning in 2002, these codes will be located in a separate section of CPT. Explanatory language will be added to explain the use of these codes. Category II codes are considered optional, and will not be required for correct coding. These codes will not receive any Medicare relative value units (RVUs).

Category III codes have been created to facilitate data collection on and assessment of emerging technology. These codes may be used to substantiate widespread usage or to assist during the FDA approval process. The service or procedure must have relevance for research.

Category III codes will be assigned a 5-digit alphanumeric code with the letter T at the end (eg, 1234T). Beginning in 2002, these codes will also be located in a separate section of the CPT book. In addition, Category III codes will be published twice a year on the AMA website. If after five years, these codes have not yet been given Category I status, they will be sunset, unless it can be demonstrated that a Category III code is still necessary. Like Category II codes, these will not be given RVUs.

The process for requesting a new or revised CPT code remains the same. The AMA has developed a formal coding proposal form which must be submitted to the Department of CPT Editorial Research and Development. Coding proposals must contain detailed information on the procedure described, including a clinical vignette of the typical patient and an operative report. Copies of peer-reviewed articles published in U.S. journals describing the safety and effectiveness of the procedure must be included. The proposal must also clearly indicate how the procedure is currently coded, why the existing codes are inadequate to describe the service, and exactly how the proposed addition or revision differs from any existing code.

Before going to the CPT Editorial Panel, all coding proposals are first circulated to the AMA CPT Advisory Committee for review. The Advisory Committee is made up of representatives from all specialty societies in the AMA House of Delegates. If any of the advisors believes a coding proposal has merit, it is forwarded to the Editorial Panel for its decision.

Even if a requester submits a proposal to create a new Category I CPT code, the CPT Editorial Panel may decide that the proposal warrants a Category II or Category III code instead. Because codes in these two classifications do not have any RVUs associated with them, there is some concern that private payers may also refuse to reimburse for these "emerging technologies." In order to receive a Category I code, the coding proposal must have strong accompanying literature on the efficacy of the procedure.

The AAOS CPT and ICD Coding Committee recommends that individual orthopaedic surgeons forward any coding request to the committee prior to submission to the AMA. The members of the committee can provide a great deal of expertise in drafting coding proposals and assisting them through the approval process.

Coding requests may be addressed to CPT and ICD Coding Committee, American Academy of Orthopaedic Surgeons, 6300 North River Rd., Rosemont, Ill. 60018-4262.

Because the CPT Editorial Panel reviews more than 350 major coding topics per year, it has established strict deadlines for all proposals. In order to be considered for the 2003 CPT manual, all coding proposals must be submitted to the AMA no later than October 8, 2001.

Laura Nuechterlein is senior policy analyst in the AAOS department of health policy.

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