How to Apply for, or revise, a CPT Code - New Technology Pathway
The Physician Payment Policy Workgroup (3P), co-chaired by James Denneny III MD, and Jane Dillon MD, the Coordinators for Socioeconomic and Practice Affairs, is the senior advisory body to Academy leadership and staff on issues related to socioeconomic advocacy, regulatory activity, coding/reimbursement, and practice services/management.
The 3P group evaluates inquiries for new technology coding and requests for new Current Procedural Terminology (CPT) codes or revisions to existing CPT codes. Members of 3P, including Richard Waguespack, MD, Bradley Marple, MD, and Lawrence Simon, MD, represent otolaryngology interests on the AMA CPT Advisory Committee. Our CPT representatives advocate for otolaryngology by presenting new and revised CPT codes to the CPT Editorial Panel for inclusion in the code set used for physician billing.
When it comes to valuing CPT codes, the 3P group serves as the expert consensus panel to analyze surveys completed by Academy members and make recommendations for appropriate Relative Value Units (RVUs) to the AMA/Specialty Society Relative Value Update Committee (RUC) for otolaryngology-related codes. Some of these members (Wayne Koch MD, Charles Koopmann MD, MHSA, John Lanza MD, Jane Dillon, MD, Pete Batra MD, and Peter Manes, MD) also represent the Academy at the RUC meetings. The RUC makes recommendations on the Relative Value Units (RVUs) of new and revised physician services to the Centers for Medicare and Medicaid Services (CMS). The RUC also performs broad reviews of the Resource Based Relative Value System every five years and rolling reviews of many codes based on screens such as high utilization, frequency of codes used together, and codes not surveyed since the beginning of the RUC process over twenty years ago.
To provide a more streamlined process, consistent with approaches adopted by other specialty societies, 3P initiated development of the New Technology Pathway, a process approved by the Board in September, 2010 that the Academy has adopted and now requires for any requests for guidance on how to code for a new technology, new CPT codes for services or procedures, or revisions or revaluations of existing codes. The newly formalized process includes coordination between 3P and experts from other applicable AAO-HNS Committees (i.e., Medical Device and Drug Committee, CPT/RVU Committee, etc.) as a way to incorporate all of the resources of the Academy in the interest of the members. We are confident that the New Technology Pathway will address such requests in a manner which is clearly defined, consistent with AMA CPT and RUC guidelines, accounts for the interests and perspectives of all stakeholders while protecting against undue influence of any group or individual, encourages the collection of reliable data, and promotes efficient, fair reimbursement for our members and appropriate access to new procedures and services for our patients.
The New Technology Pathway starts by completing the "New or Revised CPT Code Application", an internal Academy document.
For the AAO-HNS statement on new technology and information about communication procedures and lobbying policies, please see the “AAO-HNS New Technology Pathway Requests Policies and Procedures” document above.
Inquiring parties, including physicians and industry representatives, should send the completed package to the Academy’s staff Jenna Kappel, Director, Health Policy at JKappel@entnet.org.
AMA Criteria for all CPT codes:
- The proposed descriptor is unique, well-defined, and describes a procedure or service which is clearly identified and distinguished from existing procedures and services already in CPT.
- The descriptor structure, guidelines and instructions are consistent with current Editorial Panel standards for maintenance of the code set.
- The proposed descriptor for the procedure or service is neither a fragmentation of an existing procedure or service nor currently reportable as a complete service by one or more existing codes (with the exclusion of unlisted codes). However, procedures and services frequently performed together may require new or revised codes.
- The structure and content of the proposed code descriptor accurately reflects the procedure or service as typically performed. If always or frequently performed with one or more other procedures or services, the descriptor structure and content will reflect the typical combination or complete procedure or service.
- The descriptor for the procedure or service is not proposed as a means to report extraordinary circumstances related to the performance of a procedure or service already described in the CPT code set; and
- The procedure or service satisfies the category-specific criteria set forth below.
AMA Criteria for Category I Code
- All devices and drugs necessary for performance of the procedure or service have received FDA clearance or approval when such is required for performance of the procedure or service.
- The procedure or service is performed by many physicians or other qualified health care professionals across the United States.
- The procedure or service is performed with frequency consistent with the intended clinical use (i.e., a service for a common condition should have high volume, whereas a service commonly performed for a rare condition may have low volume).
- The procedure or service is consistent with current medical practice.
- The clinical efficacy of the procedure or service is documented in literature that meets the requirements set forth in the CPT code change application.
AMA Criteria for Category III Code
- The procedure or service is currently or recently performed in humans; AND
At least one of the following additional criteria has been met:
- The application is supported by at least one CPT or HCPAC advisor representing practitioners who would use this procedure or service; OR
- The actual or potential clinical efficacy of the specific procedure or service is supported by peer reviewed literature which is available in English for examination by the Editorial Panel;OR
- There is a) at least one Institutional Review Board approved protocol of a study of the procedure or service being performed, b) a description of a current and ongoing United States trial outlining the efficacy of the procedure or service, or c) other evidence of evolving clinical utilization.