Reimbursement
Current Procedural Terminology Codes(CPT)
In one line
AMA-maintained codes used to report medical procedures and services for billing.
Definition
CPT codes are five-character codes maintained by the American Medical Association that describe medical, surgical, and diagnostic services. Category I codes describe established services; Category III codes describe emerging technologies.
The AMA CPT Editorial Panel meets several times a year to review applications for new and revised codes, and the AMA/Specialty Society RVS Update Committee (RUC) recommends values to CMS. Category II codes track performance measures. For a new device procedure, a dedicated code usually needs FDA authorization, published clinical evidence and evidence of use by many physicians across the US.
Why it matters
Reimbursement strategy for new devices often hinges on whether an existing Category I CPT code adequately describes the procedure or whether a Category III, then Category I application is needed.
Common pitfalls
- •Misinterpreting Category I codes as sufficient for novel procedures, potentially leading to claim denials.
- •Failing to apply for a Category III CPT code for new technology, delaying reimbursement.
- •Not understanding the specific documentation requirements associated with particular CPT codes.
- •Using an unlisted CPT code without proper justification and accompanying documentation.
Sources