How a Procedure Gets a Current Procedural Terminology (CPT) Code …from Idea to Valuation

Author:Kim Cavitt, Au.D.

As Congress takes up the discussion of the Sustainable Growth Rate (SGR) and its repeal begins to take center stage in Medicare reform discussions on Capital Hill, this is an excellent opportunity to discuss how a procedure gets to a CPT code and how, once that code is created, the new code is valued.

We first should note that the American Medical Association owns CPT codes. It is specifically the CPT Editorial Panel, which is a division within the AMA, which maintains these codes. The Editorial Panel is made up of 17 members. These 17 members are made up of the following:
  • Eleven are physicians, who have been nominated by the national medical specialty societies and which are approved by the AMA Board of Trustees; one of these physicians must be an expert in performance measurement.
  • One physician represents the Blue Cross and Blue Shield Association.
  • One physician represents America’s Health Insurance Plans.
  • One physician represents the American Hospital Association.
  • One physician represents the Centers for Medicare and Medicaid Services (CMS).
  • Two seats represent representatives of the CPT Health Care Professionals. Advisory Committee (both the American Academy of Audiology and the American Speech-Language-Hearing Association have seats within this advisory committee).
The Editorial Panel meets three times each year to evaluate, discuss and approve codes, which have been proposed. These codes are updated annually and released in the Federal Register on or about the first Monday in November. Here is the eight step process that outlines how a clinical procedure or service gets a code and a value.
Step 1: Proposal Created for a New CPT code
The need to create a new CPT code can come from two common places: the profession or the Centers for Medicare and Medicaid Services (CMS) via the American Medical Association.

While anyone may put a code request forward, codes are typically put forward by national provider associations. For audiologists there is a committee, which is presently convened by ASHA. This committee meets monthly to discuss these types of issues. The following associations are afforded the opportunity to have representation in this process via this committee, including:
  • American Speech-Language-Hearing Association
  • American Academy of Audiology
  • Academy of Doctors of Audiology
  • Academy of Rehabilitative Audiology
  • American Academy of Private Practice in Speech Pathology and Audiology
  • Association of VA Audiologists
  • Directors of Speech and Hearing Programs in State Health and Welfare Agencies
  • Educational Audiology Association
  • Military Audiology Association
  • National Hearing Conservation Association
Step 2: CPT Application is completed
In order to complete the application, the following criteria must be met:
  • The proposed code description is unique, specific, and describes a procedure or service which is clearly identified and clinically different from any existing procedures and services already defined in CPT.
  • The descriptor structure, guidelines and instructions were created in accordance with the guidelines set forth by the CPT Editorial Panel for the code set in question.
  • The proposed code description accurately reflects how the specific procedure or service as typically performed.
  • All devices required to perform the procedure or service have received FDA clearance or approval when such is required.
  • The procedure or service is commonly performed by many audiologists in the United States.
  • The procedure or service is consistent with current best practices in audiology
  • The clinical efficacy and utility of the procedure or service is documented in peer reviewed, US professional literature.
Click here to learn more about the specifics of this application.
Step 3: CPT Panel Reviews the Proposed Code
There are several possible outcomes of the CPT Editorial Panel review process. Code submitters receive their determination within three weeks of the CPT Editorial Panel meeting. The Panel can do one of the following
  • Accept the code as written.
  • Accept the code with modification.
    • The submitting body has ten days to submit a request for reconsideration.
  • Reject the code.
    • The submitting body has ten days to submit a request for reconsideration.
  • Postpone the code request.
Step 4: Code is Approved…What’s Next?
Well, now is the fun part. The code begins the valuation process, which ultimately determines how much a provider receives every time they perform a procedure.

Every code goes through the process of being valued via the Resource-Based Relative Value Scale (RBRVS). This valuation includes calculations based upon work value (how much time and effort it takes to complete a procedure), practice expense (how much it costs to complete a procedure) and malpractice. It is this resulting value that is multiplied by the geographical cost index adjustment and the conversion factor (determined by Congress) that becomes the reimbursement for a given item of procedure.

This process is called the RUC (RVS Update Committee). Let’s give a bit of background to help define what all of this means. The RUC has 31 members representing the following:
  • Twenty-one physicians are appointed by specialty medical societies.
  • Four seats rotate, on a two-year basis, including a representative from primary care, two representatives from internal medicine and one representative from a medical society not already represented within the RUC
  • The remaining six seats are held by:
    • The RUC Chair
    • The Co-Chair of the RUC HCPAC (Health Care Professional Advisory Committee)
      • Audiology is represented at the RUC HCPAC by ASHA, who allows for all audiology stakeholders organizations to be equally allowed to participate in the process via the monthly committee meetings mentioned above in the CPT process
  • American Medical Association
  • American Osteopathic Association
  • Chair of Practice Expense Committee
  • Chair of CPT Panel
Step 5: RUC Considers Code
The RUC receives the code from the CPT Editorial Panel. At this point, RUC members can do one of the following:
  • Survey professionals, which this code is applicable to, to gather data involving the work involved with the provision of this procedure.
  • Comment in writing on values developed and proposed by other societies.
  • Take no action as the code has no impact on their specialty.
Typically, as it pertains to audiology codes, otolaryngology and neurology frequently comment on audiology codes.
Step 6: Survey Stakeholders
This is where audiologists come into play and where their input is valuable. Audiologists will receive a survey from organizations of which they are a member. If an audiologist routinely performs this procedure in question as a course of practice, they should complete this survey once. This data is invaluable in determining how much time and effort it takes to routinely perform this procedure. It is this data that is used by the stakeholder organizations to make a recommendation to the RUC HCPAC about how a code would be valued.
Step 7: RUC HCPAC
This is where the survey data is first taken to defend and determine what value should be given to a specific procedure or service. It is this value that is ultimately taken to the entire RUC Committee for final determination and approval. You must get a two-thirds majority for your code valuation to pass the RUC.
Step 8: Publication
The final code and value are published in the Medicare Physician Pay Schedule.
What Does This All Mean to Me?
  • Complete surveys when they are sent to you if you perform the procedure and be honest in your answers.
  • Be aware of what is going on in the world of coding and who and how you are being represented in that process.
  • Become involved in coding and reimbursement issues in your state and through your national association.
References
Applying for CPT Codes: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/applying-cpt-codes.page
2013 RVS Update Process: http://www.ama-assn.org/resources/doc/rbrvs/ruc-update-booklet.pdf    
Kim Cavitt, Au.D. was a clinical audiologist and preceptor at The Ohio State University and Northwestern University for the first ten years of her career. Since 2001, Dr. Cavitt has operated her own Audiology consulting firm, Audiology Resources, Inc. She currently serves on the Board of the Academy of Doctors of Audiology and the State of Illinois Speech Pathology and Audiology Licensure Board. She also serves on committees through AAA and ASHA and is an Adjunct Lecturer at Northwestern University.