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Economics
Creating a CPT® Code
What are CPT® codes?
CPT® is a listing of descriptive terms and identifying codes for
reporting medical services and procedures. The CPT® codes are maintained
and copyrighted by the American Medical Association and have been
adopted by the Secretary of the Department of Health and Human services
as the standard for reporting physician and other medical services. CPT®
codes provide a means of communicating medical procedures among
physicians, patients and third party payers. CPT® stands for Current
Procedural Terminology.
How is a CPT® Code Developed?
CPT® codes are developed through a formal application procedure.
Specialty societies such as the ACR become aware of new technologies
that require a new CPT® code for reporting and reimbursement and then
prepare a detailed application that includes justification for the new
code and references to the medical literature. The decision to implement
a new code is made by the CPT Editorial Panel, a 17-member panel that
includes 11 practicing physicians appointed by the AMA. 2005 CPT code
additions include codes for PET, PET/CT, and carotid stenting.
So the code is approved… when do I get paid?
Creating a new CPT® code is just the first step in the process. There
are several types of CPT® codes: Category I codes are created for
established procedures. The requirements for a Category I code are very
stringent: the procedure must be performed nationally, supported by US
peer-reviewed literature, and approved by the FDA if necessary. Category
III codes are assigned to emerging technologies for procedures that are
not yet ready for Category I status. The Category III codes are used to
report procedures so that overall utilization can be tracked. Category
III codes are not sent to the RUC for valuation, but they are sometimes
reimbursed at a local level by Medicare or other payors.
How does the work that I do translate into a CPT® code?
The process of coding for the work that we do everyday can be very
complex. Each CPT® code is based on a very specific descriptor that
specifies the components of each code. It is crucial to understand the
codes carefully so that each examination or procedure is coded
appropriately. Failure to include codes for work that you do will
result in underpayment. Including additional codes inappropriately will
result in overpayment and is considered fraud. See the article from Dr.
Thorwarth in the JACR (References and Useful Links) for an excellent
description of how your dictations translate into CPT® codes.
See the next section on reimbursement to better understand what happens next.
Author:
Sanjay K Shetty, M.D.
Chair and Councilor
Continue reading to learn about the details of the process.
Learn more:
- Creating a CPT® Code
- Assigning a Value to the Code
- Reimbursement
Other links:
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