Every fall, healthcare professionals anxiously await the release of the Medicare Physician Fee Schedule (PFS) Final Rule, which outlines policy changes for Medicare payments under the PFS and updates to other Medicare Part B payment policies.
What the Final Rule doesn’t fully explain is the journey that brought us here.
How did these codes, the ones we use daily for documentation and billing, come into existence?
Why are they defined the way they are, and how are their values determined?
More importantly, who is involved in shaping these codes?
Behind the scenes, a systematic and carefully structured process ensures that every code is not only defined but appropriately valued. This process, driven by the American Medical Association (AMA) and supported by specialty societies like the American Speech-Language-Hearing Association (ASHA), American Physical Therapy Association (APTA) and American Occupational Therapy Association (AOTA), involves multiple steps, layers of review and input from healthcare professionals across disciplines.
Let’s walk through this step-by-step, so you can better understand how these critical codes come into existence and the role of professional advocacy in ensuring they reflect the services you provide.
Step 1: Identifying the need for a new CPT® code
The first step in the process of creating a new CPT® code is identifying a need for the code. This can arise when new medical procedures, technologies or treatments are developed.
Healthcare providers, professional societies, medical device manufacturers or other stakeholders might recognize the absence of a CPT® code for a particular service, making documentation and reimbursement difficult.
Specialty societies like ASHA, APTA and AOTA are integral in this phase. They gather feedback from their member speech-language pathologists, physical therapists, and occupational therapists to identify emerging practices or gaps in the existing CPT® code set. These organizations serve as advocates for their respective disciplines, ensuring that the needs of rehabilitation professionals are considered when new codes are proposed.
Step 2: Submission of a proposal to the CPT® Editorial Panel
Once a need is identified, stakeholders, including specialty societies, can submit a formal application to the AMA’s CPT® Editorial Panel. This panel, consisting of medical professionals and experts, is responsible for overseeing the CPT® code set. The application must include detailed information about the service or procedure, its purpose, clinical efficacy, and how it differs from existing codes.
The CPT® Editorial Panel meets three times a year to review proposals, and this is where specialty societies such as ASHA, APTA and AOTA often present their case. They provide clinical evidence, input from their member practitioners and insights on the widespread adoption of a procedure.
The panel considers key criteria, such as:
- Clinical evidence: Is there sufficient research to justify a new code?
- Widespread use: Is the service being performed frequently across various healthcare settings?
- Distinctiveness: Does the new procedure offer unique benefits or differ significantly from current practices?
The involvement of specialty societies is crucial in gathering the necessary evidence to meet these criteria.
Step 3: The role of the RUC process
Once a CPT® code is approved, the next step is determining its reimbursement value through the Relative Value Scale Update Committee (RUC). The RUC, formed by the AMA in 1991, is responsible for recommending the relative value units (RVUs) associated with each CPT® code, which ultimately determines how much healthcare providers will be reimbursed for the service.
Specialty societies such as ASHA, APTA and AOTA are key participants in the RUC process, as each has representation within the RUC. Their role includes:
- Participating in RUC surveys, which gather data on physician/qualified health professional (QHP) time, practice expense, and work intensity.
- Advocating for fair RVUs that reflect the time, complexity and resources required for rehabilitation services.
- Presenting data on the unique aspects of rehabilitation services to ensure they are accurately valued in comparison to other healthcare procedures.
These organizations work directly with the RUC to ensure that rehab services are appropriately valued, factoring in both clinical complexity and the resources required to deliver them.
Step 4: Publication and implementation
After the CPT® Editorial Panel approves the new CPT® code and the RUC assigns relative value units, the code is published in the CPT® Manual, typically with an effective date for the following calendar year which generally is what we see published in the Medicare Physician Fee Schedule final rule.
Furthermore, we have ASHA, APTA, and AOTA to thank for the critical role they play following rule-making in educating their members on how to implement the new codes.
Specialty societies are truly indispensable throughout the entire CPT® code creation process.
These organizations advocate on behalf of speech-language pathologists, physical therapists and occupational therapists to ensure that the services they provide are recognized, appropriately coded, and appropriately reimbursed.
In closing, the healthcare landscape continues to evolve therefore understanding the CPT® code creation process empowers therapists to stay involved in advocating for the recognition and value of their work.
Staying engaged with the CPT® Editorial Panel and RUC, ensures that rehab professionals have a voice in shaping the CPT® code set and that the reimbursement structure supports their work!
Renee Kinder, MS, CCC-SLP, RAC-CT, serves as the Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she contributes her expertise as a member of the American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, the University of Kentucky College of Medicine community faculty, and an advisor to the American Medical Association’s (AMA) Current Procedural Terminology CPT® Editorial Panel, and a member of the AMA Digital Medicine Payment Advisory Group. For further inquiries, she can be contacted here.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
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