Current Procedural Terminology (CPT)

Overview

Procedural coding by physicians has evolved from a rudimentary classification system used mostly for research purposes to a dynamic tool that reflects the rapid advancements in healthcare. The first Physician's Current Procedural Terminology was published by the AMA in 1966, and it was periodically revised until the fourth edition, which was published in 1977 as CPT-4, Current Procedural Terminology—4th Edition. Since then, the basic format has been retained, and all subsequent printings of CPT use the CPT-4 design. The revised Current Procedure Terminology is published annually, and the new revision takes effect each January 1. The AMA owns and develops CPT-4, and attempts by others to develop a medical procedural coding and medical nomenclature system have not been as widely recognized.

The acceptance of CPT-4 was enhanced in 1983, when the U.S. Department of Health and Human Services (HHS) signed a contract with the AMA designating CPT-4 as the standard coding system for describing physicians' and other healthcare providers' services for Medicare and Medicaid. The Resource Based Relative Value Scale (RBRVS) is based on the CPT-4 coding. The Resource Relative Value Scale is a system used to determine physician reimbursement, and numerical relative values are assigned to each CPT code. This value is multiplied by a dollar conversion factor, updated yearly by the Centers for Medicare and Medicaid Services (CMS), to determine payment levels for physician and other healthcare services. Third-party insurance companies and others have adopted [Page 276]the same method of payment as the CMS based on CPT-4 coding.

The AMA/CPT Editorial Panel maintains, updates, modifies, and revises CPT-4. The AMA/CPT Editorial Panel is composed of 19 members selected by the AMA for 4- or 8-year terms. There are 13 physicians who represent selected medical and surgical specialties, in addition to a chair and vice-chair. The CMS, third-party medical insurance carriers, nonphysician providers, and the American Health Information Management Association (AHIMA) each have one member on the panel. The AMA/CPT Advisory Committee and AMA Health Care Professionals Advisory Committee also provide input into the AMA/CPT Editorial Panel. Additionally, there are 91 medical and surgical societies and 17 healthcare professional society representatives selected by the AMA for participation.

Code Categories

The CPT-4 publication divides physician services into three categories. Category I codes are based on procedures consistent with contemporary medical practice performed by many physicians in clinical practice. Category I code criteria include approval by the Food and Drug Administration (FDA) of any drug or device; the service being a distinct procedure and/or service performed by many physicians and/or practitioners; the clinical efficacy of the service and/or procedure being well established in peer-reviewed literature; the service and/or procedure being neither a fragmentation of an existing procedure or service nor currently reportable by one on more existing codes; and the suggested service and/or procedure being not a means to report extraordinary circumstances related to the performance of a service and/or procedure already having a specific CPT code. The CPT-4 coding system assigns a five-digit number to each code in Category I.

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