Procedural Terminology

[Fatima Teem]

TheCurrent Procedural Terminology (CPT) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency.

The CPT terminology is the most widely accepted medical nomenclature used across the country to report medical, surgical, radiology, laboratory, anesthesiology, genomic sequencing, evaluation and management (E/M) services under public and private health insurance programs.

The development and management of the CPT code set rely on a rigorous, transparent and open process led by the CPT Editorial Panel. Created more than 50 years ago, this AMA-convened process ensures clinically valid codes are issued, updated and maintained on a regular basis to accurately reflect current clinical practice and innovation in medicine.

All CPT codes are five-digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that a diverse set of users can have common understanding across the clinical health care paradigm.

For more than 50 years, CPT has been the primary medical language used to communicate across health care, enabling seamless processing and advanced analytics for medical procedures and services. The CPT code set is constantly updated by the CPT Editorial Panel with insight from clinical and industry experts to reflect current clinical practice and the latest innovations to help improve the delivery of care.

The CPT Editorial Panel, appointed by the AMA Board of Trustees, is responsible for maintaining and updating the CPT code set. The CPT Editorial Panel is an independent group of expert volunteers representing various sectors of the health care industry. Their role is to ensure that code changes undergo evidence-based review and meet specific criteria.

The CPT Editorial Panel is supported by CPT Advisors, groups of physicians nominated by the national medical specialty societies represented in the AMA House of Delegates and the AMA Health Care Professionals Advisory Committee (HCPAC). As clinical experts in their fields, the primary role of CPT Advisors is to advise the CPT Editorial Panel on procedure coding and appropriate nomenclature by proposing revision to the code set, working with industry stakeholders as they consider additions and changes to CPT, and in educating their membership on the use and benefits of CPT codes.

The CPT Editorial Panel meets three times a year to review the applications for either new codes or revisions to existing codes. Anyone who wishes to participate can submit an application to attend a Panel meeting.

As medicine evolves with clinical innovations such as genomic testing and remote patient monitoring, physicians, innovators and any other stakeholder working within the health care space will need to assess whether a new or updated CPT code is needed to describe their innovation.

Data drives our health care system with medical innovation to improve patient care. The CPT code set stands primed and ready to grow and change with input from stakeholders across the health care landscape.

The Current Procedural Terminology (CPT) code set is a procedural code set developed by the American Medical Association (AMA). It is maintained by the CPT Editorial Panel.[1] The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. New editions are released each October,[2] with CPT 2021 being in use since October 2021. It is available in both a standard edition and a professional edition.[3][4]

CPT coding is similar to ICD-10-CM coding, except that it identifies the services rendered, rather than the diagnosis on the claim. Whilst the ICD-10-PCS codes also contains procedure codes, those are only used in the inpatient setting.[5]

CPT is identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Healthcare Common Procedure Coding System. Although its use has become federally regulated, the CPT's copyright has not entered the public domain. Users of the CPT code set must pay license fees to the AMA.

CPT II codes describe clinical components usually included in evaluation and management of clinical services and are not associated with any relative value. 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 PMAG is composed of performance measurement experts representing the Agency for Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA) and the Physician Consortium for Performance Improvement. The PMAG may seek additional expertise and/or input from other national health care organizations, as necessary, for the development of Category II codes. These may include national medical specialty societies, other national health care professional associations, accrediting bodies and federal regulatory agencies.

Category II codes make use of an alphabetical character as the 5th character in the string (i.e., 4 digits followed by the letter F). These digits are not intended to reflect the placement of the code in the regular (Category I) part of the CPT codebook. Appendix H in CPT section contains information about performance measurement exclusion of modifiers, measures, and the measures' source(s). Currently there are 11 Category II codes. They are:

CPT II codes are billed in the procedure code field, just as CPT Category I codes are billed. Because CPT II codes are not associated with any relative value, they are billed with a $0.00 billable charge amount.[10]

The CPT code revisions in 2013 were part of a periodic five-year review of codes. Some psychotherapy codes changed numbers, for example 90806 changed to 90834 for individual psychotherapy of a similar duration. Add-on codes were created for the complexity of communication about procedures. Family therapy and psychological testing codes were among those that were unchanged.[12]

CPT is a registered trademark of the American Medical Association, and its largest single source of income.[13] The AMA holds the copyright for the CPT coding system.[14] However, in Practice Management v. American Medical Association[15] the U.S. Court of Appeals for the Ninth Circuit held that while the AMA owned the copyright, it could not enjoin a competitor on the basis that the AMA had misused its copyright.[16] Practice Management had argued that the publication of the CPT into federal regulation invalidated the copyright; the general debate around copyright and regulation access was revived in 2012[17] by a petition motivated by an Administrative Conference of the United States recommendation.[18]

Despite the copyrighted nature of the CPT code sets, the use of the code is mandated by almost all health insurance payment and information systems, including the Centers for Medicare and Medicaid Services (CMS), and the data for the code sets appears in the Federal Register. It is necessary for most users of the CPT code (principally providers of services) to pay license fees for access to the code.[19]

In the past, AMA offered a limited search of the CPT manual for personal, non-commercial use on its web site.[20] CPT codes can be looked up on the AAPC (American Academy of Professional Coders) website.[21]

CPT is a registered trademark of the American Medical Association (AMA). The CPT Category I (CPT I) codes are a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. The purpose of the terminology is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby provides an effective means for reliable nationwide communication among physicians, patients, and third parties.

Each CPT category 1 code corresponds to a single procedure or service. The intent of CPT codes is not to transmit all possible information about a procedure or service; the intent is to identify the procedure or service. The CPT code for a name is unique and permanent.

CPT Category III (CPT III) codes are temporary alphanumeric codes for new and developing technology, procedures, and services. They are for data collection, assessment, and in some cases, payment of new services and procedures that currently do not meet the criteria for a CPT I code.

There are annual updates to CPT codes. For questions regarding the use of CPT codes, contact the AMA CPT Information and Education Services at 800-634-6922 or at the AMA website. Measure developers should account for contractual timelines when considering applying for new concepts.

CPT refers to a set of medical codes used by physicians, allied health professionals, nonphysician practitioners, hospitals, outpatient facilities, and laboratories to describe the procedures and services they perform.

In 1966, the American Medical Association (AMA) created CPT codes to standardize reporting of medical, surgical, and diagnostic services and procedures performed in inpatient and outpatient settings. Each CPT code represents a written description of a procedure or service, removing the subjective interpretation of precisely what was provided to the patient.

The AMA updates CPT nomenclature, or medical language, to reflect advances in medicine. Although the AMA owns the copyright to CPT, the AMA invites providers and organizations to participate in the ongoing maintenance of the code set, welcoming those who use it to suggest changes to codes and code descriptors.

A second exception to numerical code order involves evaluation and management (E/M) codes. As shown in the Category I code outline below, E/M codes are printed first in CPT code books, although they start with the number nine. The AMA chose this order because E/M services are the most often reported healthcare services. This arrangement, as with resequenced codes, is designed for coding efficiency.

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