Which Category Is Used To Report Service For Patient Seen In Stand-alone Ambulatory Care Centers/

Adv Wound Care (New Rochelle). 2013 Dec; ii(10): 583–587.

CPT^® Codes: What Are They, Why Are They Necessary, and How Are They Developed?

Received 2013 Jul 22; Accepted 2013 Oct 9.

Abstract

Qualified healthcare professionals (QHPs) demand to identify the professional services they provide and to report those services in a way that tin exist universally understood past institutions, individual and regime payers, researchers, and others interested parties. The QHPs' information are used to track healthcare utilization, identify services for payment, and to gather statistical healthcare information about populations. Each twelvemonth, in the Usa, healthcare insurers process over 5 billion claims for payment.^one To ensure that healthcare data are captured accurately and consistently and that health claims are processed properly for Medicare, Medicaid, and other wellness programs, a standardized coding system for medical services and procedures is essential. The Current Procedural Terminology (CPT^®) organization, developed by the American Medical Association (AMA), is used for just these purposes. The AMA system provides a standard language and numerical coding methodology to accurately communicate beyond many stakeholders, including patients, the medical, surgical, diagnostic, and therapeutic services provided by QHPs. The CPT descriptive terminology and associated code numbers provide the nearly widely accepted medical nomenclature used to report medical procedures and services for processing claims, conducting research, evaluating healthcare utilization, and developing medical guidelines and other forms of healthcare documentation.

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Groundwork

History of Current Procedural Terminology coding development

The showtime publication, in 1966, of the American Medical Association (AMA) Current Procedural Terminology (CPT^®) edition of standardized codes and terms was a means to code procedures (mainly surgical) for medical records, insurance claims, and data for statistical purposes.

By 1970, the AMA had broadened the arrangement of terms and classification codes to include diagnostic and therapeutic procedures in surgery, medicine, and the specialties besides as procedures relating to internal medicine. This timeframe also coincided with the introduction of the five-digit numeric coding system. With the release of the 4th edition of CPT in 1977, the AMA introduced a arrangement for periodic updating of the codes to keep up with the ever-changing medical environment.

In 1983, CPT was adopted every bit part of the Centers for Medicare & Medicaid Services (CMS), Healthcare Common Procedure Coding System (HCPCS). This HCPCS code set is divided into two principal subsystems: (1) Level I of the HCPCS, which comprised the CPT and (2) Level II of the HCPCS (see Marcia Nusgart'southward article).^i,ii

Level I CPT codes are the numerical codes used primarily to identify medical services and procedures furnished by qualified healthcare professionals (QHPs). CPT does non include codes regularly billed by medical suppliers other than QHPs to report medical items or services. The AMA is responsible for all decisions for additions, deletions, or revisions of the CPT codes [Level I HCPCS lawmaking set up]. CPT codes are updated annually.

In 1983, CMS mandated that CPT codes be used to report services for Part B of the Medicare Programme and in 1986 required state Medicaid programs to as well apply the CPT codes. Equally part of the Omnibus Budget Reconciliation Act in 1987, CMS mandated utilize of CPT for reporting outpatient hospital surgical procedures. As office of the Wellness Insurance Portability and Accountability Act (HIPAA) of 1996, the Section of Health and Homo Services designated CPT and HCPCS as the national standards for electronic transaction of healthcare information.

Today, the CPT coding organisation is the preferred system for coding and describing healthcare services and procedures in federal programs (Medicare and Medicaid) and throughout the Usa by private insurers and providers of healthcare services.

Types of CPT codes

The CPT code can be identified past one of the following three categories.

Category I CPT codes depict distinct medical procedures or services furnished by QHPs and are identified by a 5-digit numeric code [eastward.g., 29580: Unna boot]. New Category I CPT codes are released annually.

Category Ii CPT codes are supplemental tracking codes, too referred to equally performance measurement codes. These numeric alpha codes [e.yard., 2029F: complete physical skin examination performed] are used to collect data related to quality of care. Category II codes are released three times a year in March, July, and November by the CPT Editorial Panel.

Category III CPT codes are temporary tracking codes for new and emerging technologies to allow data collection and assessment of new services and procedures. They are used to collect information in the FDA blessing process or to substantiate widespread usage of the new and emerging engineering science to justify establishment of a permanent Category I CPT code. Category 3 CPT codes are issued in a numeric alpha format [due east.g., 0307T: near-infrared spectroscopy study for lower extremity wounds].

New Category 3 CPT codes are released biannually (January and July) with a 6-month delay before activation for implementation in the Medicare organization. Codes released on January 1st are constructive July 1st, and codes released on July 1st are effective January 1st. The codes usually remain active for v years from the date of implementation, if the code has not been accustomed for placement in the Category I department of CPT.

Obtaining a CPT Level III code requires less clinical information and has a shorter review timeframe. It allows billing and tracking through the local and regional contractors for Medicare and other payers. There are no assigned fees to these codes, just payment is available at the discretion of the Insurance Carriers or Medicare contractors. When considering payment, the Medicare contractors and insurers consider prove of effectiveness, improved outcomes, and potential cost savings.

Criteria used by the CPT Advisory Commission and the CPT Editorial Panel for evaluating Category 3 code for emerging engineering science include any one of the following for consideration:

1. A protocol for a written report of procedures being performed.
2. Back up from the specialties that would employ the procedure.
3. Availability of U.S. peer-reviewed literature.
4. Descriptions of current U.S. trials outlining the efficacy of the procedure.

Word

Who manages the CPT process?

The responsibleness to update or change code descriptors, coding rules, and guidelines for the CPT code set lies with the AMA CPT Editorial Panel, authorized by the AMA Board of Trustees. The panel comprised 17 members [11 physicians nominated past the national medical specialty societies; 4 physicians nominated from the Blueish Cross and Blue Shield Association, America's Health Insurance Plans, the American Hospital Clan, and the CMS; and ii seats reserved for members of the CPT Health Care Professionals Informational Committee (HCPAC)]. Five of these members serve as the panel's Executive Commission. In add-on, the CPT Informational Commission supports the panel. Members of CPT Informational committee are primarily physicians nominated past the national medical specialty societies represented in the AMA House of Delegates also as the AMA HCPAC, organizations representing limited license practitioners and other allied health professionals. The Operation Measures Advisory Group, which represents diverse organizations concerned with performance measures, likewise provides expertise.

How is a new code developed?

Any individual QHP, medical specialty guild, hospital, third-party payer, and other interested political party may submit an application for changes to CPT for new or revised codes to the CPT Editorial Panel. This ongoing procedure has a schedule for submission deadlines and meetings of the CPT Panel, which tin exist found on the AMA site.³ It is of import to sympathise that an applicant needs to carefully plan to submit their request in the appropriate timeframe to coincide with the scheduled meetings for the CPT Editorial Console reviews.

Step 1: AMA staff determines if the asking is new

If the Editorial Panel has already reviewed the request, the staff will notify the requestor of the panel'southward coding recommendation. If the request is a new upshot or includes significant new data on an detail that the panel reviewed previously, the application moves to stride 2.

Step ii: Refer application to the CPT Advisory Committee for evaluation and commentary

The process allows at least three months for the AMA staff to prepare all the submitted materials and manipulate them to the Editorial Console reviewers. Steps i and 2 are consummate when all appropriate CPT Advisors have responded and all information requested of an applicant has been provided to AMA.

Step 3: Refer awarding to the CPT Editorial Panel

The 17 member CPT Editorial Panel meets 3 times each yr and addresses about 350 major topics per year, unremarkably involving more than 3,000 votes on individual items.^iv

• AMA staff prepare an agenda detail that includes the application, compiled CPT Advisor comments, and a election for conclusion by the CPT Editorial Console.
• Thirty days earlier a scheduled meeting, the panel members receive the agenda documents and the CPT Advisor comments. The panel members can confer with experts as appropriate.
• If an applicant does not receive the CPT Advisor back up, then the applicant is notified fourteen days before each CPT Editorial Panel meeting. Applicants can withdraw their applications up until the agenda item is called at the meeting.
• Applications that accept not received any CPT Counselor back up volition be presented to the CPT Editorial Panel for discussion and possible decision.

Stride 4: CPT Editorial Panel takes an action and preliminary approvals

If applying for a Category I or Category 3 code, the CPT Editorial Panel votes and determines into which category the lawmaking(s) should be assigned. A decision can result in one of the following four outcomes:

1. Add a new code or revise the existing classification; this change would appear in a forthcoming volume of the CPT Book.
2. Refer to a workgroup for further study.
3. Postpone to a time to come meeting [to allow submittal of additional information in a new awarding].
iv. Decline the request.

Step 5: AMA staff inform the applicant of the CPT Editorial Console's determination

Applicants or other interested parties tin seek reconsideration of the console'due south decision. Data of this procedure is available on the AMA/CPT website.^v

Step six: Refer lawmaking to AMA/Specialty Guild Relative Value Update Commission (RUC)

Once the new/revised CPT codes are approved by the CPT Editorial Panel, the code is then referred to the RUC, which volition deport a survey of QHPs from relevant medical specialties that provide the service or process. This survey volition measure out the QHP piece of work involved in performing the service/procedure to determine an authentic relative value recommendation for the service.^{half dozen} The RUC commission schedule tin can be accessed at the AMA website.

Step 7: Implementation of the new/revised CPT code

• Category I service and process CPT codes are updated annually and constructive for use on Jan 1 of each year, except for Category I vaccine product codes, Molecular Pathology, which are released Jan 1st or July 1st. The new CPT book, with the newly released codes, is released in the fall to allow for implementation on January ane.
• Category II codes are released for reporting three times yearly (March 15th, July 15th, and November 15th) to become effective three months subsequent to the date of release, allowing iii months for implementation.
• Category Three codes are released for reporting either Jan 1st or July 1st of a given CPT cycle and become effective six months subsequent to the date of release.

NOTE: This unabridged new CPT Lawmaking application process tin can take from 18 to 24 months.

What do the CPT Informational Commission and CPT Editorial Console demand?

Success in obtaining a new or revised CPT code is dependent on agreement the process and preparing an application with the consummate data required. Obtaining support from the appropriate medical customs, society, or provider group that requires or endorses the need for the code is essential for the CPT approval process.

The major information requirements for a new or revised CPT lawmaking application include the post-obit.

• A complete description of the process or service (e.g., depict in detail the skill and time involved. If a surgical procedure, include an operative report that describes the process in detail).
• A clinical vignette, which describes the typical patient and work provided by the dr./practitioner.
• The diagnosis of patients for whom this procedure/service would exist performed.
• A copy(southward) of peer reviewed manufactures published in the U.S. journals indicating the safe and effectiveness of the process.
• Frequency with which the procedure is performed and/or estimation of its projected performance.
• A copy(s) of additional published literature, which further explains the request (e.g., do parameters/guidelines or policy statements on a item procedure/service).
• Evidence of FDA approval of the drug or device used in the procedure/service if required.
• Rationale why the existing codes are non adequate and tin any existing codes be changed to include these new procedures without significantly affecting the extent of the service?

Where can I find more than data?

The AMA website has all the information bachelor concerning the CPT process, access to the application forms, the schedule for the CPT Editorial Console, and the afterthought process forms.⁷

CPT is a registered trademark of the AMA.

Abbreviations and Acronyms

AMA	American Medical Association
CMS	Centers for Medicare & Medicaid Services
CPT	Current Procedural Terminology
HCPCS	Healthcare Common Procedure Coding System
HIPAA	Wellness Insurance Portability and Accountability Act
QHP	qualified healthcare professional

Author Disclosure and Ghostwriting

No competing financial interests be. No ghostwriters were used to write this article.

Almost the Author

Peggy Dotson, RN, BS, earned her nursing diploma in 1971 at Our Lady of Lourdes School of Nursing (Camden, NJ), and graduated from Philadelphia Academy (Philadelphia, PA) in 1993 with a Available's of Scientific discipline degree. She has 9 years of feel in clinical practice working in surgical, coronary care, intensive intendance, and as a field trainer for the Mercer County Paramedic Projection in New Jersey. She worked for 23 years in Bristol-Myers Squibb'southward ConvaTec Division in varying roles, including clinical trial monitor for ostomy, wound intendance, and incontinence devices; medical sales representative; sales management; international marketing; worldwide business development; and Managing director of Reimbursement & Payer Alliances, analyzing the U.Southward. healthcare market place and developing strategic approaches for the company. Since 2003, she is the owner and President of Healthcare Reimbursement Strategy Consulting, which evaluates healthcare policy, coverage, coding, and payment issues, and the impact of reimbursement on the healthcare market. She serves the Association for the Advancement of Wound Care (AAWC) as the Chair of the Regulatory Commission (2008 onward) and a member of the AAWC Quality Measure out Job Strength and Finance Committees. Since 2012, she serves on the Board of the Brotherhood for Wound Care Stakeholders.

References

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