Current Procedural Terminology (CPT) as developed by the American Medical Association (AMA) represents a comprehensive effort to describe physician services. CPT has evolved into the single standard method for tracking and billing physician services. To maintain the coding system and provide a mechanism for revising codes as technology and medical practice evolved, the AMA formed the CPT Editorial Panel and a network of CPT advisers representing the various medical specialties.
Although anyone can submit a request for a CPT code, significant hurdles are encountered when proposals are presented without the involvement of a medical specialty society. To facilitate effective advocacy for future proposals, this article highlights examples of the interactions of industry with organized medicine in the CPT coding process.
Submitting a Code Proposal
Before a code proposal can be approved, several requirements must be met. First, the physician service must be performed in the United States with sufficient volume and breadth to warrant code development. Second, physician services that use devices should have Food and Drug Administration (FDA) approval. Finally, the efficacy of the physician service should be supported by independent evidence in U.S. peer-reviewed publications. The AMA distributes proposals quarterly to the CPT advisers for comment. Subsequently, the proposed codes are debated at the panel regarding merit as well as to refine language. If the panel does not accept a proposed code, it can be tabled for discussion at subsequent meetings or resubmitted to the panel after revision. A common reason that the panel does not accept codes is failure to attain consensus among medical specialty societies.
Proposals Encounter Pitfalls: Examples
Several years ago, after the FDA approved percutaneous intradiscal therapy, two different manufacturers worked independently to develop and submit code proposals. However, support of the medical specialty societies was not obtained. The proposals were tabled and resubmitted on several occasions. Although a multidisciplinary societal presentation was given, several panel members expressed strong criticism concerning the limited peer-reviewed data available. A conflict of interest from the business relationships between some of the authors and industry further impeded panel acceptance, resulting in the creation of a temporary level III tracking code.
Contrast this experience with the development and successful navigation of intracavitary chemotherapy delivery through the FDA process. Industry representatives were prepared to submit a code proposal, but they first sought the advice of the Coding and Reimbursement Committee (CRC). Wide application and usage was prevalent and peer-reviewed data was available, but an additional component of physician work needed to be identified beyond that accounted for in the craniotomy code. When this was accomplished, the CRC proceeded with the development of a CPT proposal, which was accepted and included in CPT 2003. This example highlights the subtle but critical difference between codes for a product or technology (for which an independent coding system outside the purview of the AMA exists) and a CPT code for a physician service.
As a third example, a medical specialty society developed a code proposal for fracture reduction with vertebral augmentation. A series of meetings aided revision of the code in preparation for submission. However, only a limited number of publications addressing the efficacy of the technology compared to currently available treatment methods was found. Despite wide application, FDA approval, identified additional physician work, and multispecialty society interest, the committee elected to delay proposal submission until additional published data assessing the impact of this technology on patient outcome were available.
Physician Services Versus Technology
These examples highlight the hurdles and pitfalls encountered when industry develops technology that is used by physicians. It is imperative to understand that the CPT process identifies unique physician services not otherwise described, rather than devices or technology. However, it is even more critical to understand that expensive new devices and technology further strain the healthcare dollars available. For example, payment for technology and devices often is sought by industry through diagnosis-related groups (DRGs) of the hospital Medicare Part A system; however, using these expensive technologies and devices in the outpatient setting brings them into the Medicare Part B formula, creating a negative impact on the funds available to pay for physician services.
This has placed hospitals, industry and physicians in the position of trying to influence how these limited funds are distributed. Physicians continue to advocate for more appropriate reimbursement with some limited success. We must take a leading role in defining the introduction and usage of expensive devices and technology, as the payment for technology results in fewer dollars available to reimburse the physician for the actual healthcare service provided.
Gregory J. Przybylski, MD, is professor and director of neurosurgery at JFK Medical Center in Edison, N.J. He is a member of the AANS/CNS Coding and Reimbursement Committee and he is on the faculty for AANS coding and reimbursement courses. He is also council director of socioeconomic affairs for the North American Spine Society and program chair of its coding update courses.