Renee Kinder
Renee Kinder

It’s that time of year again when the Current Procedural Terminology (CPT) Editorial Panel meets with the task of ensuring its codes remain up to date and reflect the latest medical care provided to patients. 

The panel maintains an open process and convenes meetings three times per year to solicit the direct input of practicing physicians, medical device manufacturers, developers of the latest diagnostic tests and advisors from over 100 societies representing physicians and other qualified health care professionals.

Why should you care?

Well, there are many reasons.

To begin, understanding how codes are created, developed and monitored is essential for ensuring accuracy of billing and coding when providing patient care. 

CPT® descriptive terms and identifying codes serve a wide variety of important functions. 

The system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. 

When considering documentation audit accuracy, CPT® is used for administrative management purposes such as claims processing and developing guidelines for medical care review.

As such, after therapy teams and providers understand how codes are developed, they can then appreciate the appropriate means for documenting skilled care associated with each CPT® definition. 

Having this understanding can provide additional proactive protection when used to support internal documentation audits.

Let’s begin with some history on how codes are created. 

  • 1966 The American Medical Association first developed and published CPT in 1966. The  first edition contained primarily surgical procedures, with limited sections on medicine, radiology and laboratory procedures.
  • 1970 The second edition was published in 1970 and presented an expanded system of terms and codes to designate diagnostic and therapeutic procedures in surgery, medicine and the specialties. 
  • 1977 The fourth edition was published and represented significant updates in medical technology and introduced a system of periodic updating to keep pace with the rapidly changing medical environment. 
  • 1983 CPT was adopted as part of the Centers for Medicare & Medicaid Services’ Healthcare Common Procedure Coding System. With this adoption, CMS mandated the use of HCPCS to report services for Part B of the Medicare Program. 
  • Today In addition to use in federal programs including Medicare and Medicaid, CPT is used extensively throughout the United States as the preferred system of coding and describing healthcare services.

Over the course of more than five decades, no taxpayer money has been spent to develop or maintain the CPT® code set. Countless hours are spent to ensure that the CPT codes accurately reflect the medical care provided to patients.

Next, let’s discuss how codes are created. 

Medical specialty societies, individual physicians, hospitals, third-party payers and other interested parties may submit applications for changes to CPT® for consideration by the editorial panel.

First, and not surprisingly, there are specific procedures for changes to the codes and criteria for each code category exist for addressing requests to revise, such as adding or deleting a code or modifying existing nomenclature. 

Next, the AMA’s CPT® staff reviews all requests including applications for new and revised codes.

If staff determines that the request presents a new issue or significant new information on an item that the panel reviewed previously, the application is referred to members of the CPT® Advisory Committee for evaluation and commentary.

Hence, the reason for the meetings taking place next week.

Impressively, the panel addresses nearly 350 major topics a year, which typically involve more than 3,000 votes on individual items.

The panel actions (PDF) on an agenda item can result in one of four outcomes:

  • Addition of a new code or revision of existing nomenclature, in which case the change would appear in a forthcoming volume of 
  • Referral to a workgroup for further study
  • Postponement to a future meeting (to allow submittal of additional information in a new application)
  • Rejection

Thrilling right? I think so.

I find comfort when reviewing documentation standards that behind every code there is a process and the process includes educated formal discussions to get things right regarding definitions.

Want to learn more on how your therapy teams can support coding accuracy?

American Speech Language Hearing Association CPT Tools

American Physical Therapy Association Coding and Billing

American Occupational Therapy Association Educational Resources for CPT®

CPT® process resources

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).