Slides courtesy of: Richard W. Waguespack, MD, FACS
President Elect, AAO-HNS, Former CPT Editorial Panelist, CPT Advisor for the Triological
Society, Past Coordinator for Socioeconomic Affairs
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

CPT Process
• Manner by which CPT codes are created and modified by the AMA
• Role of the AAO-HNS in the process
• Rudiments of bundling/code edits
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

Current Procedural Terminology (CPT)
• The CPT code set has been developed, owned, and maintained by AMA since 1966
• Is the national standard for electronic reporting of health care information relating to physician services, designated in the final rule for HIPAA
August 17, 2000
• The code set is maintained by the AMA CPT
Editorial Panel
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

CPT Editorial Panel
• A total of 17 members – 11 physicians nominated by
Medical Societies plus one member each from:
• Blue Cross Blue Shield Association (BCBSA)
• America ’ s Health Insurance Plans (AHIP)
• American Hospital Association
• Center for Medicare and Medicaid Services (CMS)
• 2 seats for members of Health Care Professional Advisory
Committee (HCPAC)
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

CPT Editorial Panel
Executive Committee
• Editorial Panel Chair
• Co-Chair (serves as Chair of CPT Assistant
Editorial Board)
• Three Members-At-Large elected by entire
Panel (one must be a third-party payer representative)
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

CPT Advisors ’ Role
CPT Advisors
• Support the Editorial Panel
• Nominated by national medical specialty societies that are represented in the AMA House of Delegates and
AMA HCPAC
• Serve to give specialty-specific advice on coding and nomenclature to Editorial Panel
• Give support to CPT staff, suggest revisions, review and promote education of membership on use of CPT
• Otolaryngology is represented by CPT Advisors from the AAO-HNS, Triological Society, AAOA, and AAFPRS
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

Types of Codes: Category I or III?
• Category I
• “ Standard codes ” but does not “ guarantee ” carrier payment
• Higher threshold of usage, literature support, standard of care
• Category III
• New technology and less literature support
• May be used for tracking
• FDA approval not required
• Not valued by RUC but may be paid by carriers
• Unlisted and Category II codes
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

CPT Development
Who can propose a new or request modifying an existing CPT code?
• Individual person or institution
• Specialty society
• AMA CPT Editorial Panel members or staff
• Medical device or drug company
• Payer (commercial or governmental)
• RUC (AMA Relative Value Update CMTE)
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

The CPT Process
• Who can propose or modify a CPT code?
• Individual person or institution
• Specialty society
• AMA CPT staff
• Medical device or drug company
• Payer, commercial or governmental
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

The CPT Process
• Who can propose or modify a CPT code?
• Individual person or institution
• Specialty society
• AMA CPT staff
• Medical device or drug company
• Payer, commercial or governmental
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

Academy CPT Development
• Who as an Otolaryngologist can request a new or revised CPT Code?
• Individual AAO-HNS member
• AAO-HNS standing committees, (e.g., Sleep Disorders, Rhinology
Paranasal Sinus)
• Medical device or drug company
• Subspecialty society, (e.g. AAOA (Serial Endpoint Titration Editorial
Change)) or others, (e.g. ASHA (cochlear implant programming codes))
• Requests for code changes or revaluation must be reviewed by the New Technology Pathway.
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

Academy Review: New Technology Pathway
Academy Staff Intake of inquiry
Updates
Board
Health Policy Report/3P
Board representatives
3P (Physician Payment Policy Workgroup)
• Initial evaluation and communication to inquiring party, Academy staff, and 3P group – James C. Denneny, III,
M.D., Socioeconomic Coordinator.
• Assess appropriate coding based on committee input, CPT literature criteria, CPT code descriptors, and RUC database descriptors
• Provide input and guidance for progression of -99 and Category III codes to Category I
•Lead the CPT process including creation and presentation of CCPs
•Lead the RUC process including creation, administration, and presentation of surveys
Medical Device and Drug Committee (MDDC)
• Assess safety, efficacy, and adoption of new technology
CPT/RVU committee
• Assists 3P as needed with their processes
Academy Committees
• Provide information as needed to MDDC, CPT/RVU Committee, and 3P to make informed assessments
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

CPT Development
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

Bundling is a 4-Letter word
CPT is a reporting system; code edits and bundling are reimbursement policies imposed by payers
Some edits are embedded in CPT
• CPT terminology “ (separate procedure) ”
• A separate procedure is one that should not be separately reported if part of a larger service, eg, tracheostomy with total laryngectomy
• Pay Close Attention to Parentheticals ( “ Do not report… or
Report… with….
” )
• These parentheticals list codes that either should, or should not, be reported with other codes.
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE

NCCI Edits
National Correct Coding Initiative (NCCI) for
Medicare
• Developed by Correct Coding Solutions LLC and adopted with approval of CMS.
• Developed quarterly and specialty society input is sought (the Academy is very active in this process).
• May be revised after issuance with clinical support.
• Often adopted by commercial carriers but beware of carriers that “cherry pick ” edits, global periods, etc.
• NCDs/LCDs ( National/Local carrier determinations ).
Contact Health Policy staff for assistance locating this information: healthpolicy@entnet.org
EMPOWERING PHYSICIANS TO DELIVER THE BEST
PATIENT CARE