Why CPT Code Changes Receive Such Detailed Scrutiny

We recently published a post discussing the fact that changes to the CPT's remote patient monitoring billing codes have been delayed yet again. We also explained that the AMA's CPT Editorial Panel had taken up the change application but decided against it. Have you ever wondered why such things happen? Have you ever questioned why CPT code changes receive such detailed scrutiny?

 

In a post published concurrent with the most recent CPT Editorial Panel meeting in Chicago, the AMA insisted that the panel's "public process helps health innovation thrive." The post went on to explain the basics of how applications are assessed so that panel members can ultimately reach a decision.

 

Whether or not the process actually enhances healthcare innovation is a matter of opinion. CPT codes were originally developed as a billing mechanism but over time their impact across the healthcare industry has increased. Does better billing lead to thriving innovation? We will let you make that call for yourself.

 

Before a new code can be entered into the CPT code set, an individual or organization must make an application. Likewise for modifying existing codes. An application is forwarded to panel members who are tasked with evaluating it against established criteria. One of the criteria is that it is "unique, well-defined and describes a procedure or service which is clearly identified and distinguished from existing procedures and services already in CPT".

 

Panel members are looking for sufficient evidence proving that the procedure discussed in the application meets all of their requirements and would have sufficient usage to warrant the creation of a new code. They are also tasked with ensuring that the "procedure or service is consistent with current medical practice." 

 

It is important to remember that evidence matters to payers. Whether it is a private insurance company or one of the federally funded insurance programs (Medicare and Medicaid), payers rely on evidence to determine the procedures they will and will not cover.

 

It might be a stretch to say CPT Editorial Panel scrutiny drives innovation directly. But one could make the case for indirect influence. Think of it in terms of how insurance coverage impacts the availability of certain procedures and services.

 

Imagine a procedure that comes with a considerably high price tag but offers limited medical benefit. An insurance company might decide not to cover that procedure because the evidence for it is not there. Now, patients opting for the procedure need to pay out of pocket.

 

If it is too expensive, demand will often be limited. This indirectly motivates those responsible for developing new procedures to come up with things that are both medically appropriate and reasonably priced. So in a sense, CPT Editorial Panel scrutiny indirectly impacts innovation.

 

There is one exception to the high-pressure review process: CPT Category III codes. As the AMA explains in their post, "Category III CPT codes...require less evidence for adoption and are generally used to track the use of new services or procedures." This is an interesting statement given the recently rejected changes to remote patient monitoring billing codes.

 

Some of the proposed remote patient monitoring billing codes are related to the deployment and utilization of remote monitoring equipment, including how data is captured and analyzed. Equipment does need to be checked to ensure that it is working properly, but it's hard to discount that there is provider time required to review the information gathered from those devices. As such, it can be difficult to quantify how much provider work is involved because the needs and information can vary between devices.

 

At any rate, the AMA CPT Editorial Panel goes to great lengths to scrutinize applications for new and modified CPT codes. That might not mean much to you if you are a medical coder or biller, but just remember that every new or modified code you work with has undergone intense scrutiny by the panel. Changes to the code set are not implemented lightly.