How Does a Procedural Service Become a CPT Code?

Current Procedural Terminology (CPT®) is a procedural code set used for reporting medical, diagnostic, and surgical services performed by health care providers. The American Medical Association (AMA) holds the copyright to CPT and the AMA CPT Editorial Panel maintains the CPT code set. This multi-disciplinary expert Panel—in charge of revising, updating, or modifying the codes and their descriptions—is made up of 17 members, 11 of which are physicians nominated by the national medical specialty societies (with one specializing in performance measurement), while the remaining seats are filled with representatives from the:

  • Centers for Medicare and Medicaid Services (CMS)

  • Blue Cross and Blue Shield Association

  • America’s Health Insurance Plans

  • American Hospital Association

  • CPT Health Care Professionals Advisory Committee (HCPAC)

The CPT Editorial Panel is supported by the CPT Advisory Committee, a group chiefly made up of physician representatives from major medical specialty societies, the Health Care Professional Advisory Committee (HCPAC), and the Performance Measures Advisory Committee (PMAC). The Advisory Committee reviews new and revised code proposals and submits recommendations to the CPT Editorial Panel for final action.

Code Proposals

Although ACOG is heavily involved in all procedural code proposals related to the work that ob-gyns perform, ACOG does not direct the code development process. Any individual or group may apply for a new code or for modification of an existing code.

Certain criteria must be met in order for a service to be given a new CPT code. In general, the CPT code development/modification process requires the following:

  • A formal application

  • That the clinical efficacy of the service/procedure is well established and documented in U.S. peer review literature (at least 5 peer-reviewed publications);

  • That the service/procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs;

  • That the suggested procedure/service is a distinct service performed by many physicians/practitioners across the United States; 

  • That the suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes; 

  • That the suggested service/procedure is not requested to report extraordinary circumstances related to the performance of a procedure/service already having a specific CPT code.

  • Consensus from medical specialty societies who will use the new code(s) or who currently use an existing code or codes to report the service

All CPT change requests must include a clinical vignette that reflects the typical (not the average) patient and thus represents the typical physician work involved in the procedure or service. The vignette follows a code throughout its life. The AMA/Specialty Society Relative Value Scale Update Committee (RUC) uses this same vignette during the development of a code’s value for work and practice expense.

Additional information about the CPT code process, meeting schedules, and code application can be found at www.ama-assn.org/practice-management/cpt-current-procedural-terminology.

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