By Marc R. Nuwer, MD, PhD, FAAN
The Academy participates in the Current Procedural Terminology (CPT®) process by submitting new codes and changes to existing codes, and by commenting on code changes proposed by other societies.
The American Medical Association (AMA) owns the rights to the CPT code set, which is maintained by the CPT Editorial Panel ("Panel"). The Panel meets three times each year to discuss and approve any CPT code additions, deletions, and revisions. An updated CPT manual is published yearly. The Academy's representatives review all proposed changes and, when appropriate, submit comments or requests for changes. The Editorial Panel considers these written comments. The Academy's CPT representative attends Panel meetings and speaks about any issues of relevance to neurology.
I serve as the representative from the Academy to the Panel; a role referred to as the CPT Advisor. The Academy also has one or two alternates who perform similar services. Our CPT advisors are members of the Academy's Coding Subcommittee of the Medical Economics and Management Committee, which oversees coding, billing, and reimbursement processes. When the Academy presents our own formal proposals for new codes, one to two additional Academy members attend the Panel meeting to serve as topic experts. Those experts help during the often extended oral negotiations that take place when coding language is debated.
Current Procedural Terminology (CPT®), Fourth Edition, is a listing of descriptive terms and identifying numeric codes used for reporting medical, surgical, and diagnostic services and procedures. CPT is a widely accepted system of medical nomenclature about health care provided to patients that enables reliable communication among physicians, other health care providers, patients, and third parties.
CPT descriptive terms and numeric codes are a widely accepted. Both public and private health insurance programs require CPT codes for reporting services and procedures. Careful attention must be paid to the wording of a code and its numeric placement in the manual, so as to minimize confusion. Extra relevant information may be given as headers for a code section or parenthetical statements attached to individual codes. This additional information aims to clarify when and how a code is to be used. To make sure that coding language is clear and useful to practicing neurologists and coders, the Academy closely studies all relevant code language, section headers, and parenthetical instructions. Attention to detail is key, since this language is used for administrative claims processing by carriers and for developing guidelines for carriers' medical review.
Category I CPT codes describe services or procedures using traditional five-digit CPT codes and descriptor nomenclature.
In developing new and revised Category I CPT codes, the Advisory Committee and the Editorial Panel requires that:
For each proposed new or altered Category I code, the Coding Change Request (CCR) form is submitted to the CPT Advisors from all societies for comment prior to the Panel meeting. The CCR is an extensive document asking questions about the service, its associated ICD-9 codes, the estimated prevalence of the associated diseases, details about other codes currently used to report the service, and much more. When the Academy proposes CPT changes, the CCR is filled out jointly by the CPT Advisor, neurology topic experts, and CPT Advisors from other relevant societies. The Academy often identifies topic experts from the Academy sections. Staff edits and consolidates the various comments for CCRs before formal submission.
Each code change proposal is reviewed by the CPT Advisor before each Panel meeting. Typically, about one hundred new code requests are reviewed before each meeting. This is done online. The CPT Advisor submits electronic comments on the proposals relevant to neurologists. Sometimes comments are made about codes that might not seem relevant to neurologists, but could be problematic—for example, by inflating national medical care costs that, because of budget neutrality provisions, could cause decreased payment for neurologic services.
After a new code is approved, it is referred to another AMA committee—the AMA/Specialty RVS Update Committee (RUC)—for determination of physician work relative value units (RVUs) and practice expense RVUs.
Category II codes are reviewed by the Performance Measures Advisory Group (PMAG), an advisory body to the CPT Editorial Panel and the CPT/HCPAC Advisory Committee. The Academy works closely with measure development panels to represent the AAN at PMAG meetings.
The Academy has a separate committee process to propose new Category II codes, 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. This category of CPT codes is a set of optional tracking codes for performance measurement. Category II codes are identified by the letter "F" at the end of the code. For each performance measure topic, the measure development panel co-chairs, facilitators, and the Academy's staff liaison work closely with the PMAG panel and AMA/PMAG staff to develop the corresponding CPT II codes. The PMAG holds an in-person meeting to review the measures with the measure developers, and suggestions are then taken back to the full panel, where they are discussed and either accepted or rejected.
CPT codes for performance measurement are not referred to the RUC for valuation because no relative value units (RVUs) are assigned.
This category of codes facilitates data collection and assessment of new services and procedures, often ones that are still investigational or not yet ready for a regular Category I CPT code. One use of these codes is to collect data to substantiate widespread usage or during the FDA approval process. Category III CPT codes do not need to meet the usual CPT code requirements about widespread use, FDA approval, or literature demonstrating clinical efficacy. The service/procedure must have relevance for research or development of future Category I codes.
Category III CPT codes are assigned an alphanumeric identifier with the letter T in the last field (e.g., 0123T). Sometimes these codes are referred to as tracking codes, and these codes are in a separate section of the CPT manual, with their own introductory language to explain their purpose. Requests for Category III CPT codes follow the existing procedures for new or revised CPT codes; however Category III CPT codes are not referred to the RUC for valuation because no RVUs are assigned.
Once approved by the Editorial Panel, newly added Category III CPT codes are made available on a semi-annual basis via electronic distribution on the AMA/CPT website.
The Academy will request a Category III code for a new or emerging technology or if there are not yet enough users of the service or procedure in question, with the hope of elevating the code to Category I status once there is sufficient literature, users, and data. That is why it is imperative that physicians report Category III codes whenever appropriate so as to help the Academy track their use. Once a Category III code achieves widespread use and is proven in US peer-reviewed medical literature, the Academy may choose to request that it be moved to the Category I section of CPT. Category III codes will automatically sunset after five years if the code has not been accepted for placement in the Category I section of CPT, unless it is demonstrated that a Category III code is still needed.
The CPT Editorial Panel is responsible for maintaining the CPT code set. This panel is authorized by the AMA Board of Trustees to revise, update, or modify CPT codes, descriptors, rules, and guidelines. The Panel is comprised of 17 members. Of these, 11 are physicians nominated by the National Medical Specialty Societies and approved by the AMA Board of Trustees. One of the 11 is reserved for an expert in quality performance measures. One physician is nominated from each of the following: the Blue Cross and Blue Shield Association, America's Health Insurance Plans, the American Hospital Association, and the Centers for Medicare and Medicaid Services (CMS). The remaining two seats on the CPT Editorial Panel are reserved for two members of the CPT Health Care Professionals Advisory Committee (HCPAC). The HCPAC is the organized group of non-physician health care professionals. HCPAC membership includes psychologists, podiatrists, physical therapists, and other allied health practitioners. This allows those groups a voice in coding and a pathway to alter codes that pertain to their areas of practice.
Five members of the Editorial Panel serve as the panel's Executive Committee. The current chairman is a radiologist.
Supporting the CPT Editorial Panel in its work is a larger body of CPT advisors, the CPT Advisory Committee. Currently, membership on the Advisory Committee is limited to national medical specialty societies seated in the AMA House of Delegates and to the HCPAC. Additionally, the Performance Measures Advisory Committee (PMAC)—a group that represents various organizations concerned with performance measures—provides expertise.
Within the past 24 months, Dr. Nuwer has received occasional payments for creating medical-legal reports, giving testimony, or performing external peer review on medical records from peer-review companies. In addition, he has served as Honorary Consulting Editor for the Journal of Clinical Neurophysiology and as a member of the editorial board for Practical Neurology. Within the past five years, he has received research support from NIH, in the form of a SBIR grant for work as a principal investigator related to a commercial firm.