ASRA Pain Medicine Update

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Author

Kevin Vorenkamp, MD, FASA
Member, AMA CPT Editorial Panel
Member, ASRA Practice Management Committee

Introduction

Current Procedural Technology (CPT®) is the designated code set for reporting services and procedures performed by physicians and other qualified healthcare professionals. It is owned and operated by the American Medical Association (AMA). The CPT manual, published annually, contains lists of descriptive terms and identifying codes using uniform language that accurately describes medical and surgical diagnostic and therapeutic services.

CPT itself does not consider value or coverage of services. Subsequent valuation of services starts with the AMA/Specialty Society RVS Update Committee (RUC), which provides recommendations for value to the Centers for Medicare and Medicaid Services (CMS). CMS ultimately determines the final valuation for these services (Figure 1).

Absent a National Coverage Determination, Medicare coverage policies for services are determined by Medicare Administrative Contractors (MACs) in their individual jurisdictions. There has been some consolidation of the various MACs within the Medicare system, but the presence of multiple vendors still allows for regional variation in coverage for services. Private payers and Medicaid sometimes follow Medicare’s policies and sometimes establish their own. The likelihood of coverage and payment is improved by having a Category I CPT code, but the existence of a Category I code does not guarantee payment. For example, CPT code 62287 (percutaneous disc decompression) is a Category I code, but there is, in fact, a National Coverage Determination that does not allow for payment of these services for Medicare patients. Conversely, although ultrasound-guided cervical facet joint/medial branch blocks are described by Category III codes (0213T–0215T), some payers are willing to provide coverage and payment for these codes.

The CPT Editorial Panel consists of 17 members. Of these, 11 are nominated by specialty societies, 4 are from relevant payer and hospital stakeholders (CMS, Blue Cross Blue Shield, American Hospital Association, and America’s Health Insurance Plans), and 2 are from the Health Care Professionals Advisory Committee (HCPAC). HCPAC is comprised of non-physicians who provide care and use CPT codes to report their professional services.

Categories of CPT codes

Category I

• Commonly performed and consistent with contemporary practice
• Five characters—numeric (64490, 99213)
• One release date per year—effective January 1
• Cannot be edited, changed, or modified unilaterally
  • New, revised, or deleted codes must go through the CPT process
• Must meet criteria for Category I status
• Must meet literature requirements

Criteria for Development/Evaluation of CPT Category I codes (Modified from https://www.ama-assn.org/practice-management/criteria-cpt-category-i-and-category-iii-codes)

• Has FDA approval for specific uses of devices or drugs
• Is a distinct service performed by many physicians and qualified healthcare professionals across the United States
• Is not a fragmentation of an existing procedure or service
• Is not currently reportable by existing code(s)
• Is not being requested as a means for reporting extraordinary circumstances related to a procedure or service already described by an existing code(s)
• Clinical efficacy is well established and documented in peer reviewed literature in the United States

Category II

• Performance Measurement
• Five characters—alphanumeric (1125F, 1130F)

Category III

• Emerging Technologies that do not yet fulfill Category I criteria
• Five characters—alphanumeric (0213T)
• Two release dates per year—released January effective July and released July effective January
• Deleted after five years if not resubmitted for Category I consideration unless there is compelling evidence to retain (eg, emerging literature not yet sufficient to meet Category I code requirements, request to retain by a medical specialty)

Process and Timeline for CPT Code Creation

There are many factors to consider before initiating efforts to create a new code, including the need to demon-strate frequency and efficacy and the effect that the addition of a new code may have on existing codes. Ideally, a newly created code achieves the “triple aim” of accurately describing a service that can be fairly valued and is covered by payers.

A “requestor” may submit a CPT code change application (CCA) for consideration at an upcoming CPT meeting. The application is often submitted by a specialty society but may also be submitted by representatives of industry, individual physician(s), or AMA staff. Although not required, support from societies whose members perform the service improves a CCA’s likelihood of success. The services described in the CCA may be original ideas or may be requests for clarification of existing services or procedures by CPT, RUC, CMS or other payers.

After the CCA is submitted, it is reviewed by AMA CPT staff to ensure the application is complete and all requirements are met. The application is then reviewed by specialty society advisors who can provide comments on the application with clinical expertise, voice support or on-support, or provide suggestions for edits or modifications to the application. Members of the CPT editorial panel then review the application for merit and consideration. Although 2 to 4 members are typically assigned as primary reviewers to present the CCA to the CPT, every application is reviewed by each of the panel members prior to the meeting. In the weeks leading up to the panel meeting, members of the panel also review all submitted literature for the application to determine whether the procedure has documented efficacy and whether the literature criteria are satisfied. Panel members may communicate through assigned AMA CPT staff with questions, comments, or concerns regarding the CCA or the services described within it. Up until the time of presentation at the CPT meeting, the applicants may modify or withdraw their application based on the responses they receive from the specialty advisors and panel members.

If a new Category I code is approved, it goes through the RUC valuation process in the weeks immediately following the CPT meeting and then, finally, through the CMS proposed and final rule process. The ultimate effective date for the code may be 1 to 2 years after the application is submitted. For example, a CCA submitted by the June 25, 2018, deadline will be reviewed at the September 2018 CPT meeting for publication in the 2020 CPT manual. This is based on CMS’s schedule for making rules. Occasionally, CMS will determine that a code is needed more quickly and may publish a code within the CMS-maintained Healthcare Common Procedure Coding System to provide a temporary coding solution until the new code is published in CPT.

Resources

• AMA CPT® (Current Procedural Terminology). https://www.ama-assn.org/practice-management/cpt-current-proce
  dural-terminology. Accessed May 10, 2018.
• AMA CPT® Code Applications. https://www.ama-assn.org/practice-management/applying-cpt-codes. Accessed May
  10, 2018.
• AMA CPT® Editorial Panel and RUC Meetings and Calendar. https://www.ama-assn.org/practice-management/
  cpt%C2%AE-editorial-panel-process-amaspecialty-society-rvs-update-process. Accessed May 10, 2018.
• AMA Criteria for CPT® Category I and Category III codes. https://www.ama-assn.org/practice-management/criteria-cpt-category-i-and-category-iii-codes. Accessed May 10, 2018.