An Inside Look at How the CPT Is Kept Balanced and Current

To submit a request, an applicant accesses an AMA online portal. Depending on the request, the applicant may have to provide peer-reviewed literature demonstrating clinical effectiveness or data that indicate widespread utilization across the U.S. “This is all to determine whether their application could pass through the panel process,” said McGraw, adding that the AMA provides technology and staff support “to answer the question of how this world of CPT works.”

2. Refining the proposal. Once an application is within the CPT editorial panel, a panel member or two are assigned as the lead reviewer(s) “to determine whether the proposal needs to be refined,” said McGraw. Society advisors might provide supporting information during this time. “There might be one specialty society that’s in favor of an application and another that isn’t, for a variety of reasons, so part of the application process includes trying to reconcile some of those points of view,” she explained.

3. Panel discussion and vote. At the subsequent scheduled CPT panel meeting, code change applications are “put on the floor” for discussion. Applicants are present, virtually or in person, as the panel considers whether the proposal meets the criteria, and there’s a debate that may culminate with a vote or a determination for further action. Results of the meeting are published shortly thereafter.

The AMA receives hundreds of code change requests per year. For the most part, the CPT code set is updated annually, although some codes are changed twice a year or quarterly. Due to COVID- 19, the past year has been especially active (see Coded Emergency, below). “Since the pandemic, instead of having to review every single application, we implemented a consent calendar to list applications that basically meet all of the criteria for panel review,” said McGraw. While the consent calendar contains only those applications that have broad support, any person attending the meeting can “extract” an item for further panel discussion without a specific rationale, facilitating the transparency of the process. “Of the applications that go through the meeting, some volume will be rejected, postponed, or withdrawn,” McGraw said, acknowledging that a low volume of applications ultimately come through with no modification, but that the AMA is continually doubling down on its efforts to smooth the path for CPT code requests.

Working the System

Richard Waguespack, MD, became interested in CPT early in his medical career. As the recently retired otolaryngologist explains it, he really had no choice: Having gone through general medical and postgraduate training in the 1970s, Dr. Waguespack “had heard virtually nothing about the CPT system,” he said. Upon beginning his practice at a multispecialty clinic in Birmingham, Ala., however, it soon became clear to the then-newly minted physician that his work needed to be coded. “The clinic had a central business/billing office, and the sum total of my training was being given a two- or three-year-old CPT book from which to select codes,” he recalled. “After about three years, I was so frustrated with the clinic’s poor collection of my fees that I sought courses on coding and reimbursement at the American Academy of Otolaryngology–Head and Neck Surgery’s [(AAO-HNS)] annual meeting.”

Simply having a code does not, for many payers, automatically guarantee reimbursement. Each carrier has a process to determine the medical necessity of services represented in the CPT book. —Richard Waguespack, MD

Ultimately, Dr. Waguespack left that clinic. “I joined a more senior doctor, with my wife becoming office manager,” he said. “Together we learned nuances of CPT coding and healthy collection practices. She became very involved in the otolaryngology administrator group and got to know our physician leaders in health policy, especially coding and reimbursement.” When an opportunity to serve as the AAO-HNS CPT advisor opened, Dr. Waguespack took on the role. He remained involved in the CPT process for more than 20 years, during which time he also served as a specialty advisor for the Triological Society, as a member of the editorial board of the monthly publication CPT Assistant, and on the AMA CPT editorial panel.